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Insight in Psychiatry
Questions concerning the nature of insight in patients with mental illness have interested clini-
cians for a long time. To what extent can patients understand disorders which affect their men-
tal function? Does insight carry a prognostic value? Is impaired insight determined by the illness
or are other factors important? Despite considerable research examining insight in patients with
psychoses, non-psychotic disorders and chronic organic brain syndromes, results are inconclu-
sive and insight remains a source of some mystification.
IVANA S. MARKOVÁ examines the problems involved in studying insight in patients with men-
tal illness in order to provide a clearer understanding of the factors that determine its clinical
manifestation. She puts forward a new model to illustrate the relationship between different
components of insight in theoretical and clinical terms, and points to directions for future
research.
Dr IVANA S. MARKOVÁ is a Senior lecturer in psychiatry with an interest in insight, descriptive
psychopathology, the epistemology of mental phenomena and neuropsychiatry. She holds fur-
ther qualifications in history and philosophy of science. Her work in insight is widely published,
both in journals and book chapters.
Insight in Psychiatry
IVANA S. MARKOVÁ
cambridge university press
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo
Cambridge University Press

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Every effort has been made in preparing this publication to provide accurate and
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Contents
Preface ix
Part I Historical and Clinical 1

1 Historical overview 3
2 The psychological perspective: Gestalt, cognitive and psychoanalytic 34
3 Insight in clinical psychiatry: empirical studies 66
4 Insight in organic brain syndromes: insight into neurological states 128
5 Insight in organic brain syndromes: insight into dementia 151
Part II Conceptual 195

6 The conceptualisation of insight 197
7 The relational aspects of insight: the ‘object’ of insight assessment 219
8 Towards a structure of insight: awareness and insight,
an essential distinction? 243
9 Towards a structure of insight: the relationship between
awareness and insight 271
References 293
Index 327
v
For my mother and babi
DRH
Preface
Throughout history, human beings have been variously occupied with enquiries
into self-knowledge and self-understanding. In Western cultures these themes have
persistently raised vital and profound questions not just for individuals but, par-
ticularly in the last two to three hundred years, for the sciences and humanities.
Psychiatry has been no exception to this. However, although as we shall see in this
book, interest in insight in psychiatry has a relatively long past, it is only in the last
fifteen or twenty years that psychiatry has become engrossed with the empirical
question concerning the presence and nature of insight in patients with mental
disorders. It is a question that encompasses many facets. From one perspective, it
addresses in a practical way the degree of understanding patients have about their
conditions. In turn, this raises important issues relating to clinician-patient com-
munication and carries implications for the management of the individual patient.
From another perspective, however, the question of patients’ insight reaches to the
core of our understanding of mental disorders themselves. It forces us to consider,
for example, how mental functions might act and interact in health and illness.
Can mental disorders have selective effects on mental function? To what extent can
mental dysfunction in one area affect mental function or capacity in another area?
The question of insight from yet a different perspective is wider still and focuses
enquiry on the nature of self in relation to mental illness. Here, questions arise
concerning the sorts of factors that may contribute to self-knowledge and to what
degree these might differ in the ‘healthy’ individual and the person with mental ill-
ness. To what extent can the self be considered independent of the mental illness
that disturbs the very functions which are thought to constitute it? The question of
insight in patients with mental disorders is clearly not simple. Moreover, the nature
of the issues raised demands explorative processes which straddle medical, psy-
chological, philosophical and historical approaches.
A great deal of research has been carried out in order to answer different aspects
of the question of insight in psychiatry. Most such research has involved empirical
studies exploring insight in different clinical populations and examining relation-
ships between patients’ insight and a variety of clinical and individual variables.
ix
x Preface
A range of innovative measures to assess insight have been devised and approaches
to the study of insight have varied from one clinical area to another. Interestingly,
outcomes of such studies both within a particular clinical area and between differ-
ent clinical areas have been striking in their variability. Consequently, it remains
difficult to arrive at consistent answers with respect to insight in psychiatry.
Methodological issues aside, such variable study outcomes highlight the presence
of complexities around the conceptualisation of insight and its ensuing translation
into clinical forms amenable to empirical assessment. It follows that research is
needed at a conceptual level to explore the notion of insight in depth, to identify
and disentangle the complexities that contribute to many of the problems around
the study of insight.
This book is specifically concerned with the complexities surrounding the study
of insight in psychiatry. It sets out to examine the nature of these complexities in
order to help clarify our understanding of insight, to detail the factors important
in determining insight clinically and to specify assumptions underlying the clinical
phenomena elicited. Thus, on the basis of historical, clinical and conceptual analy-
ses, complexities inherent to the concept of insight are defined and localised at var-
ious theoretical and clinical levels. This allows for the formulation of a structure
for insight which delineates constitutive components and their interrelationships.
In addition, this enables the differentiation of phenomena of insight to be deter-
mined in the context of a particular clinical situation. In turn, this provides a basis
on which future empirical research on insight can be systematically developed.
The study of insight itself is a major enterprise for it entails work not only in
diverse areas, both clinical and non-clinical, but also on many levels. As such, this
is beyond the scope of this book. Instead, the book attempts to preserve a fairly
strict focus on unravelling the theoretical and practical difficulties faced by empir-
ical research on insight. Why is insight so difficult to capture clinically? How can it
be measured? Does it make sense to try to measure it in a quantitative form? What
is it about insight that makes it complicated to define or, rather, to define in an
operational way? These are the sorts of questions that are addressed by this book
with the purpose of both furthering clinical understanding of insight and devel-
oping new directions for future empirical work. Whilst approaching these issues
from an epistemological perspective, there is no appropriate room here for a wider
philosophical enquiry that might explore the notion of insight in all its possible
metaphysical dimensions.
The book concentrates on insight in psychiatry but even within this remit has
had to be selective and to set boundaries to the amount and types of material
examined. Thus, both for the maintaining of the book’s focus and for reasons of
space, there are areas that have not been covered and which are important in future
work on the subject. In this regard, for example, insight into medical illness has not
xi Preface
been included within the review section. Emphasis has been given to studies on
insight in general psychiatric disorders and in dementia. Areas which have clearly
contributed to the approaches taken to the exploration of insight in such disorders
have also been included, namely, psychological and neurological approaches.
Within general psychiatry, current studies on insight have focused predominantly
on the psychoses and affective disorders and this material is therefore reviewed and
analysed in the book. Less empirical research has been carried out on insight in
other psychiatric disorders, notably, neurotic, stress-related, dissociative disorders
or anxiety states and this is an area which again would be important to study in the
future. In fact, much of the work that has examined insight in these particular clin-
ical areas has come from the psychoanalytic psychological perspective and this is
covered in Chapter 2. The clinical reviews themselves are not aimed to be fully
comprehensive though the bulk of the work in the various areas has been covered.
For the purposes of the book, however, the clinical reviews are intended primarily
to illustrate and define the essential conceptual issues arising from the empirical
studies of insight within the respective areas. The historical chapter is restricted to
examining the concept of insight in Western cultures. It is further limited, for prac-
tical reasons, to literature in English, French and German languages.
The book is divided into two parts. The first part (Chapters 1–5) reviews and
analyses insight into mental illness from its evolution as an independent concept to
the ways in which insight has been conceptualised and explored in clinical psychi-
atry and related disciplines. Chapter 1 examines the concept of insight in mental
illness from a historical perspective, concentrating predominantly on the views
held by the late nineteenth century French alienists. This focus is the result of,
firstly, the importance and influence of nineteenth century French psychopathol-
ogy on Western psychiatry in general. Secondly, the French debates on this issue
were particularly explicit in showing how ideas on awareness and insight devel-
oped in the context of the changing philosophical and medical-pathological views
at the time. Chapter 2 explores insight from the psychological perspective and
emphasises both the differences in conceptualisation of insight held by the Gestalt,
cognitive and psychodynamic schools and the ways in which these perspectives
have influenced approaches to insight in clinical psychiatry. Chapter 3 reviews the
empirical work on insight in general psychiatry. It shows the wide range of defini-
tions of insight employed by the studies, the different approaches taken to assess
insight empirically and the mixed and inconclusive study outcomes. Chapter 4
examines work on insight and awareness carried out in neurological states and, as
such, forms an introduction to Chapter 5. In comparison with the ‘psychiatric’
notion, impaired insight or unawareness is viewed as a much narrower concept
and approaches taken to its assessment reflect this different conception. The
importance of unawareness or anosognosia in this narrow sense is stressed in the
xii Preface
light of its influence on approaches to the study of insight in dementia and in gen-
eral psychiatry. Chapter 5 reviews the empirical studies on insight in dementia. As
in general psychiatry, outcomes of such studies are variable and inconclusive.
Likewise, a range of methods have been developed to assess insight and these
have, more particularly, been influenced by approaches taken by various clinical
disciplines.
The second part of the book (Chapters 6–9) addresses the conceptual issues
raised from the earlier chapters and proposes a structure for insight that can pro-
vide a useful framework for understanding insight and its determinants. Chapter 6
focuses on the meaning and nature of insight. A distinction is made between the
concept and phenomenon of insight and the problems related to each are specified.
In turn, the implications such problems carry for the empirical study of insight are
explored. Chapter 7 examines the relational aspects of insight. It shows how differ-
ent ‘objects’ of insight assessment determine different clinical phenomena of
insight and emphasises the implications of this for the structure of insight and its
empirical assessment. Chapter 8 argues, on theoretical and empirical grounds, for
a meaningful distinction to be made between awareness and insight. Distinguishing
features between awareness and insight are described in terms of their quantitative
and qualitative aspects. Chapter 9 presents a schematic representation of the struc-
ture of insight that is based on the distinction between awareness and insight. It
shows how the phenomenon of insight can be placed within this structure, deter-
mined by it and also by the ‘object’ of insight assessment as well as the measures
used for its elicitation. The implications for understanding insight and for future
research are then discussed.
The book is based on thoughts that have developed and changed over a number
of years. I have used and built on material presented in my doctoral thesis
(Glasgow University, 1998) and on work already published. I would like to thank
the publishers of the British Journal of Psychiatry, Comprehensive Psychiatry,
Journal of Nervous and Mental Disease, Neurology Psychiatry & Brain Research and
Psychopathology for allowing me to use materials from papers of mine which
appeared in their pages. Special thanks are owed to Dr. German E. Berrios from the
Department of Psychiatry, Cambridge University, with whom I have had countless
discussions and explored many of the ideas presented here. His deep scholarly
knowledge has stimulated and inspired my own thinking and much of the concep-
tual work developed here has been the result of a joint struggle. In addition, he has
pointed me towards numerous invaluable bibliographical sources crucial for the
historical section of the book. I would also like to thank members of the AWARE
project group (Awareness in early-stage dementia: understanding, assessment and
implications for early intervention) for useful comments and thoughts in relation
to the work on insight in dementia: Dr. Linda Clare, University of Wales, Bangor;
xiii Preface
Mrs. Geraldine Kenny, North Eastern Health Board, Dublin; Dr. Barbara Romero,
Bad Aibling, Germany; Professor Frans Verhey, University of Maastricht,
Netherlands; Professor Michael Wang, University of Leicester and Professor Bob
Woods, University of Wales, Bangor. In particular, I am grateful to Dr. Linda Clare
for discussions which helped to clarify some of the theoretical aspects of this book.
I am grateful also to the University of Hull for their encouragement of this work.
Finally, I would like to thank my family for their enormous support and also my
friends and colleagues who have shown extreme patience.
Part I
Historical and clinical
1
1
Historical overview
Exploring the history of insight in mental disorders is complicated by a number of

factors. Foremost amongst these is the question as to which definition of insight to
examine. As will become evident in subsequent chapters, insight and related terms
can refer to concepts which range considerably in meaning from the very narrow
to much broader notions. For example, much of the work on insight in patients
with organic brain syndromes uses a fairly narrow concept relating to awareness of
specific problems/deficits (Marková & Berrios, 2000). On the other hand, insight
studied in general psychiatry, particularly in patients with psychoses, has tended
to be viewed in a more general sense of awareness of illness (McEvoy et al., 1989a,
b, c; Young et al., 1993, Amador & David, 2004) and/or with broader elaborations
incorporated within the concept such as additional interpretations (Greenfeld et al.,
1989), attributions (Amador et al., 1991), re-labelling (David, 1990) and self-
knowledge (Marková & Berrios, 1992a; Gillett, 1994). Then there is the notion of
insight viewed in terms of specific problem solving as in Gestalt cognitive psychology
(Sternberg & Davidson, 1995) or, different again, is the deeper notion of insight
as psychodynamic ‘comprehension’ (Richfield, 1954) and indeed the cognitive view
according to which insight is a function of some ‘mind reading system’ (Baron-
Cohen, 1995).
It could be argued that such differences in meanings of insight are simply the
result of different disciplinary perspectives (e.g. general psychiatry, clinical psych-
ology, neurology, neuropsychiatry, psychotherapy, etc.) and hence it would make
more sense to trace individual historical accounts in relation to each clinical discip-
line. Whilst this would be important in order to facilitate understanding of the
respective meanings and structures underlying insight in each case, it would not
address the problem of the general history of insight in psychiatry and the ques-
tion of whether there is a common structure or derivative to ensuing concepts of
insight or whether the commonality lies just in the usage of the term ‘insight’.
Moreover, attempting to chronicle a general history of insight in psychiatry allows
for the broadest of bases in terms of mental disorders. This is important as the sep-
aration of clinical disciplines and increasing specialisation is dependent not only on
changes in views about the nature and classification of clinical disorders but also on
the perceived needs of different patient groups. Thus, by definition, specialisation
3
4 Historical and clinical
places its own constraints on the types of patients and the sorts of disorders included
within specific categories at a particular time. This in turn affects the perspective from
which different concepts are held. Consequently, focusing solely on individual discip-
linary historical narratives might obviate the important contribution of the indi-
viduation of clinical disorders themselves towards the conceptualisation of insight.
How then to attempt a general historical account of insight in psychiatry? Berrios
(1994a; 1996) has suggested that one way of approaching the construction of a
valid historical account of symptoms or illness is to make an explicit distinction
between the histories of the terms, the behaviours and the concepts relating to the
object of inquiry. Differentiating between the histories of these aspects of insight
helps to illustrate and clarify how the meanings of insight may change not only in
time but also in relation to different contexts, whether these are social, cultural,
intellectual, etc. This approach shall thus be followed here. However, it has to be
emphasised that such distinctions in relation to the histories of insight do not
entail their independence. For example, when considering insight as a ‘behaviour’,
then clearly this cannot be considered as an a-theoretical object. Instead, interpreting
a behaviour as insightful or insightless is the result of both overt and covert concep-
tualisation. This, in turn, is dependent on a background of related concepts such as
ideas about the self, about the workings of the mind, about illness and mental ill-
ness, etc. These themselves are determined in part by the views and knowledge held
during the particular historical period of the subject. In addition, insight as a
‘behaviour’ does not directly reflect an ontological entity in the way that, for example,
a paretic gait might reflect a specific paresis. This does not mean that there cannot
be a neurobiological basis to insight but simply that at this stage, elicitation of insight
as a behaviour depends much more on conceptualisation and interpretation.
This chapter thus first examines some of the historical contexts forming the
background to insight and related notions. Then a brief overview of the history of
the term ‘insight’ is given, followed by an account of the history of the concept and
behaviour of insight. The histories of the concept and behaviour of insight are dis-
cussed together because of their particular interdependence.
1.1 Historical contexts
In medicine, the concept of insight into madness seems to have started appearing
in a consistent manner in the early part of the nineteenth century when the clin-
ical descriptions offered by alienists began to include observations concerning
patients’ awareness of their pathological state. In 1820, Georget, commenting on
the received view of madness [folie] as intellectual disorders in which patients were
unaware, remarked how whilst this was true for most patients, there was neverthe-
less a small number of patients ‘who are well able to assess their mental state, who
5 Historical overview
tell you: I have an ill head, a disturbed spirit, I can no longer think, I know that
my thoughts are disordered, I am behaving badly – but I cannot do otherwise …’
(Georget, 1820, p. 94, my translation). And by the middle and late nineteenth century,
specific debates concerning the question of insight and its relationship to different
aspects of mental illness were already taking place (Société Médico-Psychologique,
1869/1870).
In order to try to understand why insight into mental illness became an issue of
interest at this particular time and what factors helped shape its emergence, it is
necessary to look at the historical space in which this was happening. Two particu-
lar contexts will be considered here. Firstly, a brief look is given at the way in which
insight and self-knowledge were conceived in terms of the general thinking around
this time. Secondly, the changing views around the conceptualisation of madness
itself helped to influence the way in which insight into madness was conceived and
debated and, for the purposes of this chapter, more focus will be given to this area.
1.1.1 General contexts

The concept of insight in relation to the ‘healthy’ mind has been for a long time a
source of much interest to philosophers, psychologists, theologians, writers and lay
people. In Western cultures, for example, interest in self-examination is already
evident in ancient Greek philosophy. ‘Know Thyself ’ is inscribed on the temple of
Apollo at Delphi and self-knowledge was a dominant feature of Socrates’ teaching
(Plato, Charmides, 164e). According to Socrates, caring for one’s soul was the indi-
vidual’s main duty. However, only when one had self-knowledge could one care for
oneself (Plato, Alcibiades, 129b).
With the decline of the Greek culture, the interest in self-examination appeared to
diminish. Morris (1972) argued that concern about human individuality reappeared
in the eleventh and twelfth centuries, but primarily in relation to Christianity. The
emphasis in the Middle Ages on self-examination seemed to lie in the pursuit of
moral virtues and the self was viewed as under constant supervision and judgement
by God. During the Renaissance, the conception of self changed. Accompanying the
expansion in science, technology and the economy, interest became more focused
on the self as an individual and on his/her relationship with the world. Amongst the
Renaissance writers, Pico della Mirandola (1965) placed the self at the centre of the
universe. He maintained that the individual was capable of judging himself and
thus should be in control of his own life. In other words, the emphasis was on the
self as someone who could exert effects on himself and on the world and society.
In the seventeenth century interest in individuality continued to develop.
Descartes identified consciousness or awareness with thinking: ‘It is correct that
to be aware is both to think and to reflect on one’s thought … [the soul] has the
power to reflect on its thoughts as often as it likes, and to be aware of its thought in
this way …’ (Descartes, 1648/1991, p. 335). He assumed, as did Locke later, that every
experience of the individual was accompanied by self-awareness (Perkins, 1969).
Indeed, Locke went further to say that the identity of the self was determined by
consciousness (Locke, 1700/1979) though the notion of self throughout this time
was also a changing concept exerting independent as well as interdependent influ-
ences on the conceptualisation of mental illness and psychopathology (Berrios,
1993; Berrios & Marková, 2003). Nevertheless, it can be understood that con-
sciousness or awareness of self in this context was conceived as intrinsic to thinking,
feeling and experiencing rather than as a separate system that could assess such
mental operations independently.
It was later, in the eighteenth and nineteenth centuries, during the Enlightenment
and the period known as Romanticism, that the self as a whole being became the
real focus of thought. Self-awareness obtained the meaning of self-reflection and
self-consciousness in a much wider sense. In contrast to Descartes who focused
predominantly on the individual’s self, the Romanticists and some of the philoso-
phers at the time argued that self-consciousness develops mutually with the con-
sciousness of others. By being aware of others as reflexive beings, one is able to look
at oneself through the eyes of others. One becomes the object of one’s own obser-
vation (Mead, 1934; 1936). As a result, introspection became a prevailing theme of
that time (Boring, 1953). The importance of the subjectivity of inner experiences
was carried over to the psychiatry of the nineteenth century and legitimised the
elicitation of psychopathology based on patients’ accounts (Berrios, 1996).
Another important psychological concept emerging in the nineteenth century,
and influencing psychiatry and the conceptualisation of insight was that of com-
prehension (Verstehen), as developed in different ways by Brentano (1874/1973),
Dilthey (1976) and eventually, Freud, Husserl and Jaspers, amongst others (Berrios,
1992). This concept encompassed more than ‘understanding’ and more than ‘look-
ing into one’s mind’ (as suggested by introspection). Instead, it aimed to capture
the totality of one’s mental and existential state including non-conscious aspects.
The conceptualisation of insight caught within this frame thus demanded more
than an intellectual awareness of being ill but called on deeper processes involving
emotions and volitions, and that extended to a self that embraced a wider and
richer concept. The way in which such a holistic notion of insight was envisaged
depended on the particular school of thought. For example, Brentano related this
to his concept of intentionality and invoked a ‘third consciousness’: ‘Experience
shows that there exist in us not only a presentation and a judgement, but fre-
quently a third kind of consciousness of the mental act, namely a feeling which
refers to this act, pleasure or displeasure which we feel towards this act’ (Brentano,
1874/1973, p. 143). Dilthey, on the other hand, emphasised a different aspect of the
self as the focus of ‘verstehen’, namely, experience or ‘Erlebnis’. This latter concept
was conceived as the entirety of an individual’s experience, comprising internal

and external experiences (and the relationship between them) in its full historical
context (Dilthey, 1976; Apel, 1987; Makkreel, 1992). Again, this deeper view of the
self and capacity of ‘understanding’ the self enriched the general conceptualisation
of insight. Also relevant to the broad notion of self-understanding at this time was
the concept of apperception. Introduced much earlier into philosophy by Leibnitz,
to distinguish special perceptions of which man was distinctly conscious, the con-
cept was adopted in nineteenth century psychology particularly in the work of
Wundt. Associated directly with activity of the will, apperception was conceived as
the foundation of self-consciousness itself (Lange, 1906).
1.1.2 Insanity and the conceptualisation of madness

Until the early nineteenth century, the notion of madness encompassed a wide variety
of meanings predominantly from the social, cultural and political perspective and, as
such, was not generally considered a medical category (Foucault, 1971; Porter, 1990).
In this context, whilst descriptions of behaviours, viewed as insane, are plentiful and
often rich in literary and artistic colour (Porter, 1987), there did not exist the language
of descriptive psychopathology. That is to say, there was no clinical and systematic
method of capturing and classifying signs, symptoms and behaviours of abnormal
mental states (Berrios, 1996). As Berrios (1996) has shown, the latter did not develop
until the middle of the nineteenth century with the professionalisation of psychiatry
as a discipline and, inter alia, in the context of emerging views concerning subjectiv-
ity and introspection. Instead, the behaviour of madness was depicted in the language
of the lay and literary public, and portrayed as an all-or-none phenomenon. Officially,
the definition of insanity then, as offered by Hobbes and Locke in the seventeenth
century, was based on the presence of delusions (Berrios, 1994b) so that being
deluded meant being mad and vice versa. In turn, delusions by definition incorpor-
ated the notion of insightlessness. Hence, before the nineteenth century, it would
have been a logical contradiction in terms to talk about insight or awareness of delu-
sions. Condillac (1746/1924, §86, p. 55), following Locke and influential in the think-
ing of the French alienists of the early nineteenth century, defined madness in terms
of a disordered imagination (referring to delusional thinking) ‘which one is not capable
of noticing’. Thus, insightlessness was inherent to the concept of delusion and madness
and could not, in the thinking of the time, be conceived of and examined separately.
The early nineteenth century saw significant changes in the views and management
of madness. The rise in the numbers of asylums for the insane, the increased interest
shown by the physicians into the nature and treatment of insanity as well as the
development of ‘psychiatry’ as an independent profession all contributed to this
(Goldstein, 1987). Important in the conceptualisation of insight as something that
could be studied independently and in relation to madness were the changing
views around the notion of insanity as an all-or-none phenomenon. Instead, the

notion of such a total insanity was being challenged by the development of various
concepts of partial insanity. The latter was not a unitary notion but referred to a
number of different concepts and terms which seemed to evolve during the first
half of the nineteenth century. Common to these various concepts was the view
that madness could be accompanied, to a greater or lesser extent, by lucidity. This
could take place either in time, i.e. madness interspersed by lucid or sane periods,
or within the madness itself, i.e. madness could be restricted to one or a few regions of
the psyche whilst sparing others (Trélat, 1861; Legrand du Saulle, 1864; Despine,
1875). The development of the notion that insanity could be partial in these ways
was important. It opened up a space in which awareness or insight into madness
could be conceived as possible, occurring either in relation to the unaffected periods
in the course of the illness or in relation to the unaffected faculties of the mind.
Furthermore, not only was space created in which insight into madness could be
conceived, but the partial insanity debates themselves, because of their questions
concerning the nature and manifestations of madness, and the relationship between
divisions of the mind, were directly relevant to the conceptualisation of insight
into madness, particularly, in the latter part of the nineteenth century. In view of
this, it is useful to briefly look at some of the factors likely to have been influential
in the development of the concepts of partial insanity.
Probably one of the most important factors in the conceptualisation of partial
insanity relates to the empirical observations of the alienists at the time. Whilst
psychiatry as a profession did not fully emerge until near the middle of the nine-
teenth century, there was, at the turn of the century, increasing interest shown by
physicians in the treatment of the insane (Goldstein, 1987). Pinel and Esquirol in
France and Prichard in England were amongst the earliest alienists to suggest that
patients could appear to be mad in some areas of their psyche but not in others.
On the basis of his clinical observations, Pinel (1801) proposed the category ‘manie
sans délire’ to refer to insanity in patients who appeared to be afflicted by uncon-
trollable excitement and rage, and yet were able to reason and judge coherently.
Whilst later retracting the category, he continued to maintain that patients could
have ‘reasoning madness’ (‘folie raisonnante’) in which their madness was partial:
… the examples of manic patients with fury but without délire and without any incoherence in
their ideas, are far from being rare in both women and men, and they go to show how much
lesions of the will can be distinct from those of the understanding, even though they frequently
occur together.
Pinel (1809, p. 102, my translation)
Questioning how such cases could be explained if the views held by Locke and
Condillac were followed, he went on to note that patients could appear to have
lesions of the affective faculties only, or even isolated lesions involving attention,
memory, thoughts or judgement. Such observations were difficult to reconcile
with the doctrine of indivisibility of human understanding (Pinel, 1801).
More explicit and distinctive still was the concept of partial insanity promoted by
Pinel’s disciple, Esquirol and his own followers, namely that of ‘monomania’. The
monomanias comprised a range of partial insanities where the partial aspect
referred mainly to the content of the ideas/affects/behaviours around which the
madness was observed to be circumscribed. As a result, types of monomanias were
identified and named such as erotic monomania, homicidal monomania, drunk-
enness monomania, etc. (Esquirol, 1838). The concept of monomania became
extremely popular in the early nineteenth century both as a diagnosis made fre-
quently by alienists and as a defence used by lawyers in criminal proceedings
(Goldstein, 1987). In fact, challenges made by lawyers against the concept of total
insanity (as well as the opposing arguments of the prosecutors) had been prom-
inent for several hundred years beforehand (Orange, 1892). It was only when madness
became the focus of more specific medical interest (rather than a social category) and
converged with the legal interest that such debates became significant contributors to
the questions posed around the existence of partial insanities. The term ‘monomania’,
however, lost popularity and by the middle of the century was almost lost while
related concepts were developed and replaced it. What is clear, however, in many
debates about monomanias and partial insanity at that time (Guislain, 1852; Brierre
de Boismont, 1853; Delasiauve, 1853; Falret, 1866), was that discussions seemed to
be hampered by inconsistencies and sometimes contradictions concerning under-
standing of what the ‘partial’ aspect of insanity was referring to. Thus, in the case of
monomania, Esquirol himself defined this variously from a partial délire, i.e. a délire
concentrated on one or a few objects (giving rise to the types of monomanias named
above), to disorders characterised by partial lesions of the intellect or affect or the
will (giving rise to ‘monomanie intellectuelle’, ‘monomanie affective’ and ‘monomanie
instinctive’, respectively) (Esquirol, 1819; 1838). In addition, he distinguished between
lypemania and monomania on the basis of exaltation of ideas, psychological and
physical excitement in the latter (Esquirol, 1819), thereby, invoking yet another cri-
terial form. In other words, clinical observations and their analyses were occurring
at different levels and distinctions between different partial insanities were made
simultaneously on the basis of different categories. Hence, some distinctions were
made empirically, sometimes on the basis of the contents of patients’ madness, and
other times on the basis of the types of emotions or energy affecting the patients.
Yet other distinctions were made theoretically on the basis of postulated lesions of
the mind. A similar point is made by Kageyama (1984) in relation to Pinel’s classi-
fication of madness and it is likely that these inconsistencies also played a part in
the related debates around insight and awareness into illness (see below).
Another form of partial insanity was introduced by Prichard in England as

‘moral insanity’. Influenced by Pinel, Esquirol and Georget, but based on his obser-
vations, he defined the category of ‘moral insanity’ as a partial insanity charac-
terised by affective and behavioural disturbance. This particular insanity was,
he qualified, ‘without any illusion or erroneous conviction impressed upon the
understanding: it sometimes co-exists with an apparently unimpaired state of the
intellectual faculties’ (Prichard, 1835, p. 12). The important issue here is that
patients were observed as preserving some aspects of their mental function whilst
being deranged in others. Irrespective of the confusion engendered by the different
categories of distinctions made in relation to the partial insanities, the focused
clinical observations of the alienists at this time made possible the concept of par-
tial insanity itself. This in turn was necessary for the conceptualisation of insight as
an independent phenomenon.
Apart from the empirical observations of alienists, there was another develop-
ment important to the conceptualisation of partial insanity and hence insight that
contributed to the debates around the distinctions between different insanities.
This was the gradual emergence of different forms of faculty psychology. In broad
terms, faculty psychology refers to the view that the mind consists of individual
units or functions, actual or potential, which can conceivably operate, and be
affected, to varying extents, independently. This view contrasted with the associa-
tionism of Locke and Condillac that had been prevalent and influential at the time
of the early nineteenth century alienists and which held that the mind was indivis-
ible. Faculty psychology was not a unified doctrine but simply reflected the changes
in perspectives that were developing around the way in which the mind was con-
ceived as working. Ideas from some of the eighteenth century Scottish philoso-
phers, particularly Thomas Reid, provided a source of some forms of faculty
psychology. These ideas appeared to be influential in the thinking of French
philosophers and alienists during the early and middle part of the nineteenth cen-
tury (Boutroux, 1908; Brooks, 1976). Reid focused explicitly on faculty psychology
as the basis to his epistemology and conceived faculties as independent powers
(albeit working together) driving the individual operations of the mind such as
perception, memory, appetite, passions, etc. (Reid, 1785/1994). But, the nature of
faculties themselves, their origin, development, numbers, extent of independence
and relationship with other organic functions, etc. were issues that were unclear
and debated amongst philosophers and alienists at the beginning of the nineteenth
century (Rullier, 1815).
Another more extreme departure from associationism, in the early part of the
nineteenth century, was the faculty psychology promoted by Gall and Spurzheim
in the shape of the phrenology movement. Arguing explicitly against the prevailing
sensationalism, Gall introduced his organic thesis of innate faculties which were
localisable to specific organs in the brain. However, he rejected the notion that
faculties comprised of understanding, will, memory, etc. and proposed instead the
idea of specific fundamental faculties which enabled differentiation of characteristics
between individuals. In other words, his concept of faculties was that of mental qual-
ities, constitutive of both mind and character, e.g. pride/self-esteem, friendship/
attachment, sense of colours, music, verbal memory, memory for languages, etc.
(Spoerl, 1936). Arousing debates and strong criticisms (Gordon, 1815; Lélut, 1837;
1843), the phrenology movement was nevertheless important. It influenced the
views of alienists in early nineteenth century Britain (Cooter, 1979) and France
where Gall and Spurzheim’s courses were well attended by the alienists of the second
decade e.g. Georget and Leuret (Goldstein, 1987).
Alongside the debates around faculties of the mind, ideas about partial insanity
and the space in which insight into madness could become conceptualised were
also shaped by changing views concerning the causes of insanity. These in turn
related to changes in the notion of disease itself. An anonymous historian stated
in 1840: ‘all explanations of mental illness boil down to three options: they are
localised in the brain … or in the soul … or in both’ (Fabre, 1840, p. 118). Supporters
of the anatomo-clinical view of disease, including madness (Ackerknecht, 1967),
were thus more able to conceive and accept the notion of partial insanity and hence
also the possibility of insight into the diseased mental faculties. In contrast, those
who believed that insanity was exclusively sited in the mind or soul (l’âme) had dif-
ficulty in conceiving partial insanity and insight into illness since the soul was, in
terms of the philosophy of the period, indivisible and could not become partially
diseased.
The shift from the view that madness was as an all-or-none ontological entity to
the possibility that madness could be partial in different ways carried major impli-
cations for the alienists in the nineteenth century. In the context of the factors
described above, important discussions were taking place concerning the nature
and classification of mental disorders. In particular, the different forms of faculty
psychology permeating the thinking of the alienists, allowed for a more modular
conception of the mind with more or less specific cerebral localisation. This in turn
led to debates concerning the organisation and function of mental faculties, and
their role in mental illness (Société Médico-Psychologique, 1866). Delasiauve (1853)
argued that there was a categorical difference between the intellectual faculties and
the instinctive/affective faculties. Whilst the former were interdependent, the latter,
by contrast, could operate and be affected independently. Falret (1866), on the
other hand, maintained that whilst it was useful to distinguish between independ-
ent mental faculties for study purposes, it could not be assumed that mental facul-
ties operated independently in the healthy mind or could be injured independently
in the ill mind. He believed, like Maudsley did some years later, that madness even
when it affected predominantly one or a few faculties, had its effects on all. Others
disagreed and held that insanity could be specific to different faculties (Delasiauve,
1866; Société Médico-Psychologique, 1866). In a different vein, Fournet (1870)
focused on the importance of studying the relationship between mental events and
events occurring at the cellular level of the brain. He emphasised, however, that
mental activities should not be reduced to brain mechanisms and that psycho-
logical perspectives had to be preserved. It is within the context of such debates, in
the spaces formed by the conceptualisation of partial insanities and the discussions
around the independence/interdependence of mental faculties, that it became pos-
sible to conceive the existence of an insanity which could have awareness of itself.
Thus, insight and insightlessness could become meaningful concepts, variables in
their own right which could be examined in relation to and independent of insanity.
1.2 History of the word
It is interesting that the term ‘insight’ (and its equivalents) only exists in this uni-
tary form in the North and West Germanic families of languages. The Latin lan-
guages (e.g. French, Spanish, Italian, Portuguese, etc.) do not have a corresponding
unitary term and, hence, translation of insight into these languages depends on the
specific meaning of the term intended in a particular context. For example, a well-
known nineteenth century German–French dictionary translates the German
word for ‘insight’ (‘Einsicht’), as: ‘inspection, examen, connaissance de cause, bon
sens, jugement’ (Rose, 1878). Individually, all these terms carry somewhat different
meanings and hence the term chosen in a particular situation will vary according
to the specific need of the speaker. It is of note that, within the countries of the
Germanic languages, there has been more interest shown in the concept of insight
in the general thinking. Whether or not having a unitary term (insight or Einsicht)
carries implications for the conceptualisation of insight as an ontological entity
has not, however, been determined.
For the German term ‘Einsicht’, Grimm and Grimm (1862) propose as equiva-
lents the Latin terms ‘intelligentia’ and ‘judicium’, and suggest that the term gained
wider usage in the work of Goethe and Kant (Pauleikhoff & Mester, 1973).
Adelung, at the beginning of the nineteenth century, defined it as: ‘Das sinneinse-
hen in eine Sache’ [seeing into the meaning or sense of something] (Adelung, 1811,
Vol. 1). Ritter claims that the Middle German term ‘însehen’ was present in
Medieval mystical writings and meant ‘hineinsehen’ [looking into or inside], and
that J.C. Günther at the beginning of the eighteenth century discarded the religious
denotation and used ‘Einsicht’ as equivalent to personal evidence (Ritter, 1972,
Vol. 2). In addition, Ritter suggests that the ‘psychological’ meaning introduced
by Köhler (see Chapter 2) was a deviation in that it simply meant ‘intelligence’
and hence was closer to the old Aristotelian meaning of phronêsis (‘thought or
understanding’).
As far as English is concerned, the Oxford English Dictionary (2002) states that the
original notion of insight referred to ‘internal sight’, i.e. with the eyes of the mind
or understanding and provides a set of definitions generally embracing the same
metaphor, e.g. internal sight, mental vision or perception, discernment; the fact of
penetrating with the eyes of the understanding into the inner character or hidden
nature of things, a glimpse or view beneath the surface, the faculty or power of thus
seeing.
In terms of the clinical usages of the term ‘insight’, i.e. its use in relation to
mental illness, some early references to the terms can be seen in Pick (1882) as
‘Krankheitseinsicht’ or insight into illness. Similarly, the term ‘insightlessness’ was
used in Krafft-Ebing: ‘in the later stages of insanity, where delusions have become
organised or mental disintegration has ensued, the patient is completely insightless
[einsichtslos] about his disease state’ (Krafft-Ebing, 1893, p. 102, my translation).
1.3 History of the concept
Whilst there are some difficulties in arriving at a meaning that is common to the
word ‘insight’ given the differences in historical roots and terminologies between
the European countries as touched on above, there seems to be a more consistent
conceptualisation of the notion as used in clinical practice. The history of the con-
cept of insight into madness is necessarily embedded in the histories of related
concepts such as reason, consciousness and self-knowledge as well as in the histor-
ies of views around the nature of disease and insanity. Having considered some of
the historical contexts in which the concept of insight emerged, as a phenomenon
that could be examined in relation to, and independent of, madness, this section
will be concerned with the nature of the concept of insight itself and how this was
conceived in the psychiatry of the nineteenth century until the present day.
1.3.1 French views

In the early and middle part of the nineteenth century, as noted earlier, alienists
were already observing that some insane patients seemed to show awareness into
their pathological states. However, from these early observations it is evident that,
at that stage, the concept was not particularly clearly developed. Thus, descriptions
were brief and various terms were used which seemed to touch on different aspects
of awareness or insight but without these being further clarified or analysed. For
example, Pinel (1801) variously referred to either a judgement made on the part of
a patient, commenting on how sometimes a patient could, towards the end of his
episode of madness, correctly assess his state (apprécie avec justesse son état) and
himself request prolongation of admission (p. 32), or a feeling of impending illness

(sentent l’approche de leur invasion) (p. 244). Similarly, Esquirol (1838) used differ-
ent terms referring to a concept focusing either on awareness, e.g. ‘some lypeman-
ics have awareness of their state (le sentiment de leur état), they are aware (la
conscience) of the falsity, of the absurdity of the fears which torment them; they can
well perceive their disordered thinking …’ (Esquirol, 1838, Vol. 1, p. 420, my trans-
lation), or on more elaborate judgement when noting that patients could reflect on
their state (p. 124). The Belgian alienist Guislain referred to awareness in patients
(either le sentiment de leur état or la conscience), observing how some patients, par-
ticularly at the beginning of their illness, would tell others that they felt unwell, ill
or that their illness was at the point of exacerbation. In his clinical descriptions of
mental illnesses, Guislain further pointed out that ‘awareness (la conscience) could
remain intact and that the patient is able to say to himself: I am mad’ (Guislain,
1852, p. 62, my translation).
More significant focus on the concept of awareness into madness seems to have
been present by the middle of the nineteenth century. In the context of the debates
around monomanias, Delasiauve (1861; 1863; 1865) specifically designated the term
‘pseudo-monomanie’ for patients with monomania who had awareness of their
morbid condition, though a similar concept had already been present in Esquirol
when he suggested ‘lypémanie raisonnante’ (Esquirol, 1838, p. 420). In the context
of the discussions around what constituted partial madness, Baillarger (1853)
drew special attention to the concept of awareness by explicitly arguing that this
should be considered a criterion in distinguishing between patients who were and
who were not insane. His conception of insight was specifically related to the cause
that the patient attributed to the morbid symptoms. Thus, a patient with hallucin-
ations, for example, who was convinced of the reality of his hallucinations in the
outside world, based on persecutory ideas, had no insight (la conscience) and was
truly mad. On the other hand, the patient with hallucinations who realised that
these were caused by some derangement in himself, showed preservation of insight
and should not be considered truly mad. According to Baillarger, partial madness
could occur as a result of partial lesions of the understanding but insight or aware-
ness itself could not, in the same way, be partial.
Falret (1866), who embraced a wider concept of insight as patients’ awareness of
their morbid states, disagreed with the notion that loss of awareness could be used
as a criterion distinguishing between reason and insanity. He pointed out that indi-
viduals in healthy or rational states of mind sometimes could not recognise morbid
changes in themselves, and would therefore accordingly lack insight. Nevertheless,
these individuals would not be considered mad. Furthermore, he observed that
many patients ‘have perfect awareness of their states, which is in great conflict with
their ill behaviours, … with the delusional ideas imposed on them’ (Falret, 1866,
p. 387, my translation). Hence, lack of awareness into one’s state could not be used
as a criterion of madness in all cases.
A major debate specifically concerning awareness of mental illness (‘la discussion
sur les aliénés avec conscience de leur état’, Société Médico-Psychologique, 1870) was
held by the Société Médico-Psychologique in 1869/1870, and again, to a lesser
extent, in 1875. These discussions were held in the context of medico-legal con-
cerns in relation to determining responsibility of patients/individuals for criminal
and civil acts. In addition, however, the debates on awareness of mental illness
extended into related areas including the nature of madness itself, the faculties of
the mind, the notion of free will, the concept of self, and underlying brain lesions
or processes. Awareness of mental illness was discussed in relation to all these areas
and was, consequently, immersed and shaped by the problems that were being
faced in trying to clarify the latter. It is difficult, therefore, to obtain a clear defin-
ition or conceptualisation of insight in isolation. However, the debates did begin to
identify a possible structure to insight both in terms of clinical importance and in
terms of possible components.
Concerning the question of legal responsibility for criminal acts, most alienists
(Delasiauve, 1866; 1870; Falret, 1866; 1870; Billod, 1870; Girard de Gailleux, 1870;
Maury, 1870; Morel, 1870) argued that patients could have awareness of their
insane state and yet would be powerless against the urges/impulses arising from
their madness that drove them to commit abnormal acts. Hence, they should not
be held legally responsible for such behaviours. Insight or awareness was thus con-
ceived as a form of passive observation made on the part of the sane aspects of the
patient’s mind, of the abnormal urges, feelings and thoughts produced by the
insanity. The passivity of such observation was couched in terms such as ‘spectator’
(Morel, 1870) or ‘witness’ (Billod, 1870). Emphasising the importance of distin-
guishing between reason and awareness of illness, Morel (1870, p. 116) observed
that some mad patients preserved their ability to reason and yet had no awareness of
being insane. Other patients, however, could have a weakened reason which was
unable to prevent them from committing criminal acts and, nevertheless, they had
awareness of their insanity (‘aliénés irréponsables mais non des aliénés inconscients’).
In addition, the awareness of one’s mental state and actions was explicitly distin-
guished from awareness of the right and wrong of one’s actions (Morel, 1870). The
main conclusion, however, was that the ability to observe one’s madness did not
confer the ability to resist its manifestations and consequences. This view was chal-
lenged by Fournet (1870) who claimed that awareness of illness actually implied
the presence of some degree of reason and, hence, the amount of reason available
to the patient would determine the amount of responsibility for his acts. In other
words, he argued that the degree of responsibility for a criminal act was propor-
tionate to the amount of the patient’s reason. Fournet’s position was based on his
Table 1.1 Prevalence of awareness in patients admitted to Vaucluse asylum between

January and December 1869 (Billod, 1870)
Admissions to asylum
Numbers of patients with
awareness of mental illness Males (n 378) Females (n 350)
Total numbers showing awareness 61 (in 55 of these, 19 (in five of these, madness
madness followed followed alcohol excess)
alcohol excess)
Numbers with complete awareness 49 12
Numbers with incomplete awareness 12 7
views about the central role of the self in the concept of insanity (see below) and
his arguments were not generally upheld.
Discussions on awareness of mental states also raised questions concerning the
nature of mental illness or insanity. Morel (1870) pointed out that patients ranged
from having no awareness of their insanity to having full awareness and suggested
that the extent of awareness held by patients depended on the site of the lesion
causing the insanity. Thus, different insanities, with different aetiologies, not only
showed different patterns of symptoms and manifestations but also were associ-
ated with different amounts of awareness (Girard de Gailleux, 1870; Morel, 1870).
Billod (1870), reporting one of the earliest ‘empirical’ studies on awareness of ill-
ness, found that the number of patients with awareness of their pathological state
was much lower than the number of patients who lacked awareness and that
awareness was much commoner in patients whose insanity was the result of alco-
holism. He presented his own figures (see Table 1.1) and divided patients into
those with complete awareness and those with incomplete awareness of their mor-
bid state.
His distinction between complete and incomplete awareness was interesting and
raised again the issue of whether patients with awareness should be considered as
truly insane. In essence, he first of all divided patients into two categories:
1 Those patients who were not aware of their pathological state, i.e. they were aware
of strange experiences, hallucinations, disordered thoughts, etc. but attributed
those wrongly.
2 Those who were aware of their pathological state, i.e. were aware of being insane.
He then subdivided this latter category into:
(i) Patients with incomplete awareness: They were aware of their pathological
state but nevertheless believed in the reality of their delusions/abnormal
experiences. Billod viewed this contradiction between their awareness of ill-

ness and at the same time their belief in their abnormal experiences as illogi-
cal and hence signifying a lesion of judgement. Consequently, he stated, this
group of patients should be considered as truly insane.
(ii) Patients with complete awareness: They were aware of their pathological state
and, in contrast to the first group, also recognised the falseness or unreality of
their abnormal experiences even though they were still tormented by them. In
this case, Billod maintained that their judgement was relatively intact and
hence these patients should not be considered as truly insane (‘pseudo-aliénés’).
Exploring the concept of awareness further, Billod observed that following

recovery, some patients had full awareness of the state of madness in which they
had been and were able to give an exact account of what they had experienced and
could judge this as having been the product of their madness. Following up
patients longitudinally, he found that this retrospective insight was the best prog-
nostic indicator in terms of illness recurrence. Thus, he reported that patients who
had recovered from their madness but had no awareness of their previous state
showed a 60% rate of relapse or recurrence. This contrasted with 10% of patients
who relapsed after having recovered and who had shown good insight into their pre-
vious state. Indeed, Billod suggested that where patients lacked this awareness after
recovery, then this could raise doubts concerning the completeness of their recovery.
Interestingly, as the concept of insight in these discussions became more clearly
formed, particularly in Billod, different aspects of its structure were being tenta-
tively raised such as the possibility that awareness itself could vary in extent and
according to the particular insanity and the implications this carried for whether a
patient had a true insanity. In turn, these issues led to more questions concerning
the meaning of the underpinning mental and physiological structures (Delasiauve,
1870). Much debate focused on the emerging need for clarification of terms such
as ‘intelligence’, ‘reason’, ‘judgement’ and even ‘awareness’ as distinctions were being
proposed between them without consistency or clear rationale (Société Médico-
Psychologique, 1870). Many of the arguments in the discussions at this time,
however, related to the confusion engendered by the mixture of approaches taken
by the alienists. These included perspectives from the organic or physiological
together with the metaphysical and psychological, and heightened by the different
languages of each. Fournet (1870), picked up on some of these problems and
argued forcibly for the need to distinguish between the organic and the psycho-
logical in relation to reason and madness and to keep the approaches distinct without
losing their individual legitimacy. It was on the grounds of his psychological con-
ception of madness, as a removal of the soul’s authority on the self, on personality
and consequent failing or absence of free will, that he viewed awareness (and likewise
responsibility for criminal acts) as something that could be reduced proportionately

to the reduction in reason and free will. And because he conceived free will as being
the sum of the constitutive faculties of the soul, then the loss of free will was not
absolute but could occur in degrees. On this conception of madness, he distinguished
between insanity (l’insanité) where some degree of reason and awareness were
conserved, equating this with the concept of partial insanity (e.g. folie raisonnante,
folie lucide, Billod’s pseudo-aliénés), and insanity proper ( folie) where there was no
awareness or reason present. The importance of this distinction for him lay, once
more, in the issue of legal responsibility for criminal acts which he believed was
present and proportionate to the amount of awareness remaining in patients belong-
ing to the former category. Thus, Fournet’s notion of awareness was tightly embed-
ded in his psychological conceptualisation of madness. He did not disavow the
importance of brain pathology either as a primary source of the manifestations of
madness or as a secondary complication of madness. However, the essence of mad-
ness itself, he claimed, lay in the disturbance of the activity of self as an autonomous
agent, i.e. in the loss of free will. Similar views, again based on explicit distinctions
between the brain and ‘organic’ language and explanations, and the mind (or soul)
and ‘psychological’ language and explanations were shared by others, notably
Despine (1875) (see below).
As was the case in the debates held in relation to partial insanities, debates on the
concept of insight into madness were thus affected by the lack of clarity in the
terms and concepts relating to the structures of the mind and disease that were
necessary for such discussions. And, many of the disagreements evident in the
debates (Société Médico-Psychologique, 1870) reflected the differences in perspec-
tives and understanding of such structures. One specific problem in examining the
concept of awareness or insight in nineteenth century French psychiatry, is the
term ‘conscience’ itself which refers to two rather different concepts. Prosper
Despine (1875) pointed out that this was a source of confusion since psychologists
and philosophers tended to use the concepts interchangeably. He suggested that
the concepts needed to be distinguished explicitly and proposed that the term ‘con-
science morale’ should be used to refer to the English equivalent of ‘conscience’,
i.e. knowledge of the right and wrong of things. On the other hand, the term ‘con-
science personelle’ (or ‘conscienciosité’) should be used to refer to the English term
‘consciousness’. Despine defined the latter concept as knowledge of one’s mental
faculties, i.e. knowledge of what is perceived, remembered, reflected, felt, feared,
etc. and, like Locke earlier, he did not separate this from such activities themselves.
Thus, he stated that conscience personelle ‘is not a special faculty … doing and
knowing that one is doing, is the same thing’ (Despine, 1875, p. 14, my translation).
Like Fournet, Despine defined madness in psychological terms. Similarly, not
discounting the contribution of brain pathology to the manifestations of insanity,
he nevertheless conceived madness as wider than just brain disease. Indeed

patients could be afflicted by ‘folie’ and yet be healthy. Thus, madness, he believed,
lay in disturbance of the moral (i.e. instinctual/affective) faculties such that the self
(l’esprit) was no longer in control but under the influence of the ensuing abnormal
passions. Intellectual faculties (perception, memory and reflection) might be
weakened but would continue to work, albeit under the influence of such passions.
The crucial point for him was that it was not the actual abnormal passions, false
ideas and irresistible urges that constituted the madness, but the blindness of the
self (l’aveuglement de l’esprit), and hence unawareness, in relation to these patho-
logical manifestations (Despine, 1875, p. 310). His conceptualisation of insight was
necessarily bound up and determined by this same frame. Consequently, there is a
fine distinction in the way he conceived insight or awareness in patients. Thus, he
argued that, insight in the sense of consciousness (‘conscience personelle’), because
of its intrinsic link to the intellectual faculties themselves (i.e. knowledge of per-
ception, memory, etc. as above), was preserved in madness. As he said: ‘man always
has conscience personelle of acts that he carries out, even when blinded by passion, he
always knows what he is doing and can, subsequently recall it’ (Despine, 1875,
pp. 266–267, my translation). In this, he disagreed with Victor Cousin whom he cited
as stating ‘… frequently the passions, removing our liberty, remove at the same time
the consciousness of our actions and ourselves. Thus, to use common parlance, one
doesn’t know what one does’ (Despine, 1875, p. 266, my translation). On the other
hand, insight as awareness of madness itself (i.e. of the abnormal passions/impulses,
false ideas, etc.) was not possible for Despine. By definition, madness was inher-
ently unaware: ‘the one afflicted by madness cannot judge it as madness because it
is his own blindness that constitutes it’ (Despine, 1875, p. 271, my translation).
Influenced by the debates on awareness into mental illness, there emerged a
form of ‘partial insanity with awareness’ (‘folie avec conscience’ or ‘monomanie avec
conscience’) as a specific diagnostic category (Ritti, 1879). This was defined by two
essential characteristics, namely: (i) awareness on the part of the patient of the dis-
order in thinking, feeling or behaving that affected him, i.e. recognition of the
morbidity of his mental experiences and (ii) irresistibility of such morbid phe-
nomena, i.e. despite the patient’s awareness of his morbid state, he was powerless
against it. This category, in fact, referred to rather mixed conditions including
hypochondria, agoraphobia, a form of obsessional disorder and homicidal urges
with awareness. In terms of the clinical descriptions, it reflected some of the
already mentioned problems in classification of mental disorders in the middle of
the nineteenth century. However, it is an important mark in that it highlights the
recognition made at that time that different types of madness could be associated
with different extents of awareness into madness. Furthermore, awareness into
one’s pathological state could itself be used as a classificatory criterion. Indeed,
allowing for some anachronistic interpretation, this could be viewed as a point

where awareness into mental illness was becoming pivotal in distinguishing
between what were later to become the ‘psychoses’ and the ‘neuroses’.
In a classic paper on ‘Conscience et Aliénation mentale’, Henri Dagonet (1881)
focused specifically on the concept of awareness or consciousness (conscience) in
mental illness. Eschewing existing psychological and anatomical perspectives, he
was explicit in his aim to examine awareness or anomalies of awareness from a
purely clinical viewpoint. He believed that in order to better understand mental ill-
ness and its relationship to brain changes, it was essential to examine mental symp-
toms themselves. And foremost amongst these, he argued, should be the study of
anomalies of consciousness. His concept of awareness was broad and based on the
ideas of Littré and Despine. The former had defined consciousness as ‘the imme-
diate, constant, intimate feeling of the activity of the self, that is within each phe-
nomenon of moral and intellectual life’ (Dagonet, 1881, p. 369, my translation and
emphasis). Despine, as described above, had defined consciousness as ‘the know-
ledge held by the psyche of its operations, its thoughts …’ (Dagonet, 1881, p. 369,
my emphasis). Dagonet himself combined these ideas, holding that consciousness
was ‘the intimate (intime) knowledge of ourselves, of the moral and intellectual
processes going on within us’ (Dagonet, 1881, p. 370, my translation). However, he
elaborated on this further and made two important points in his conceptualisation
of awareness. Firstly, he gave awareness an active role, saying that not only did it
capture the phenomena of our internal life and committed them to memory, but it
was ‘the force which enlightens the mind (l’esprit) and directs the reason’ (Dagonet,
1881, p. 370, my emphases). Secondly, Dagonet included in his conception of
awareness, ‘the feeling of totality of the person (le sentiment de la personnalité),
undergoing the same transformations experienced by the latter under the influence
of illness’ (Dagonet, 1881, p. 370, my translation). Thus, Dagonet was broadening the
concept of awareness to include a deeper form of self-knowledge which was not
only a recipient of individual experiences but an active determinant of their nature.
Dagonet examined anomalies of awareness from two perspectives, namely, situ-
ations where awareness was temporarily lost whilst patients appeared to think, act
and feel normally, and situations where awareness or degrees of awareness were
preserved in the light of various mental and brain disorders. He observed that in
mental disorders, there existed a wide range of anomalies of awareness and illus-
trated these with examples of patients with absent or retained awareness. These
were similar to the case descriptions from the earlier debates, e.g. patients with hal-
lucinations, some showing no awareness of the morbidity of these experiences and
others appreciating exactly the phenomena affecting them and searching for explan-
ations. Interestingly, however, Dagonet also focused on the notion of modified
awareness in mental illness. This related to his concept of awareness as the feeling
of totality of a person and being subject, both passively and actively, to the changes
produced by mental disorder. Thus, he remarked, that in a number of mad patients,
this feeling of totality of the person is profoundly changed such that awareness can no
longer perceive the external world in the same way as before. Where these changes are
complete as in some cases of lypemania, hypochondria and various possession states,
then the patient becomes another personality and his awareness, his ability to perceive
and judge come under the auspices of that new personality. In other words, through its
direct connection to the self, Dagonet viewed awareness as being capable of transform-
ation by the same factors producing the madness or changes to the self. Further-
more, because of its active nature, the awareness in this new form ‘contributes to the
strengthening of the false convictions held by the individual’ (Dagonet, 1881, p. 29).
In addition, Dagonet also identified patients who appeared to show different
forms of doubling of personality (‘Doubling of personality’ was a common con-
cept in late nineteenth century psychiatry which was often used to help explain
contradictory mental states and behaviours (Berrios, 1996).) accompanied by
what he termed ‘double awareness’ (‘double conscience’). Such patients might
exhibit impulsive and violent behaviours, and be dominated by fears, hallucin-
ations and delusions but, at the same time, have ‘intimate knowledge of what is
happening to them. They judge correctly … feel that their will is insufficient to
resist against the terrible acts into which they are pushed’ (Dagonet, 1881, p. 21, my
translation). These patients would ask for help or admission to asylums. Dagonet
viewed such double awareness as a state of splitting of the psyche, whereby one state
of awareness was experiencing the bizarre phenomena of the ill personality and the
other state of awareness was judging it, according to the well personality, in a correct
manner. The resultant combination of experiences gave rise to perplexity and confu-
sion. He presented an example of a patient suffering from persecutory delusions,
believing that the whole world was concerned with him, that people were repeating
what he was saying and thinking, and making obscene gestures at him. At the same
time, the patient was analysing and studying his abnormal experiences and making
correct judgements. As Dagonet (1881, p. 21) commented,‘he knows that the impres-
sions he is experiencing are false interpretations’. Following Littré, Dagonet conceived
different forms of double awareness. In one form, the awareness was concomitant
in relation to the two personalities, i.e. both mental states had awareness and mem-
ory of each individual state. In another form, the awareness was successive, i.e. each
mental state had awareness and memory only of their own individual state but not
of the other. In a third form, the awareness was partial, i.e. when a mental state was
aware of itself but not of the new mental state but the latter was aware of both.
Dagonet believed that the awareness of illness shown by some patients could be
explained on the basis of Luy’s hypothesis of pathological asymmetry of the cerebral
hemispheres. Thus, he cited, ‘the coexistence of lucidity and delusional illness
[délire] can be rationally explained by the integrity of one cerebral hemisphere and
pathological hypertrophy of the other’ (Dagonet, 1881, p. 20, my translation). He
claimed further support for this hypothesis on the grounds of an autopsy result on
one of his mentally ill patients who had manifested clinically two distinct states of
awareness. At postmortem, there was apparently considerable difference between
the two hemispheres which suggested to Dagonet that each corresponded to the
different mental states.
Finally, Dagonet also briefly considered the medico-legal implications of his
observations. He stressed, as had the alienists in the debates some years earlier, that
patients could retain self-awareness but nevertheless be ‘forced’ into unreasonable
acts through the influence of delusional ideas. Specifically, he dissociated the
notion of awareness of illness from that of legal responsibility:
awareness should not be considered [for the physician] as a thermometer measuring degree of
responsibility … more important are the pathological phenomena characterising the mental ill-
ness. The severity of these should be determined in order to ascertain the degree of resistance
necessary for the patient to overcome dominating impulses.
Dagonet (1881, p. 32, my translation)
Seven years later, in a book examining the nature of reason in insanity and
implications for legal responsibility, Victor Parant (1888) analysed the concept of
awareness of self in mental illness (conscience de soi) in more depth. Like Morel and
Falret, he emphasised that awareness should not be confused with reason and
defined the former as a ‘state [in mental illness] in which the patient can take account
of his impressions, his actions, his internal experiences and their resultant effects’. In
other words, awareness, ‘implies not just knowledge of the mental state, but also the
capacity, in varying degrees, to appreciate and judge this’ (Parant, 1888, p. 174, my
translation). Here, therefore, seems to be one of the earliest times when the concept
of insight appears to have a more distinct form and is explicitly referring to two com-
ponent but distinct aspects, namely, awareness or consciousness of mental experi-
ences (as in Despine’s sense) and some form of judgement of these. In contrast to
Despine, Parant disagreed with Spurzheim’s view, translated by Baillarger as ‘madness
is a misfortune which is unaware of itself ’ (Parant, 1888, p. 175) and concurred with
Dagonet that patients could show a range of awareness and judgements with respect
to the mental illness affecting them. Pointing out also that this varied according to the
stage of the illness, i.e. whether early on in the illness, during the acute episode, or after
recovery, Parant (1888, pp. 177–179, 188–218) classified mentally ill patients, dur-
ing an episode of illness, into five groups on the basis of different types of awareness:
1 Those who were aware of their acts and who could judge if these were right or
wrong, but who were unaware of their morbid state.
2 Those who were aware that they were in an abnormal state but who did not
understand or would not admit that this state was insanity, e.g. patients recog-
nising the abnormality of their experiences but interpreting them delusionally.
3 Those who were aware that their mental states, acts and ideas were the result
of insanity but who, nevertheless, behaved as if they did not realise this, i.e. not
fully accepting that they had a mental illness, e.g. patients with hallucinations
and persecutory delusions, convinced by the reality of their delusional illness
and yet, at the same time, believing that they were ill.
4 Those who were aware of their morbid states and understood that these were
due to insanity but who were incapable of reacting or activating their will and
hence were powerless to do anything about it.
5 Those who were aware of their morbid states and understood that these
were due to insanity but who committed or were pushed into doing serious,
dangerous acts.
The concept of awareness or insight that Parant held thus incorporated both
awareness of mental phenomena and behaviours together with the judgement of
these as being morbid or the result of mental illness. He maintained that whatever
category of awareness the patients fell into, the presence of awareness implied
a persistence of the faculty of judgement. Interestingly, his classification of aware-
ness was based on both the subjective accounts given by patients as well as their
observable behaviours, noting the range of discrepancies between the two, and
emphasising the dissociation between patients’ judgements and their manifest
behaviours, particularly in relation to categories 3–5. Commenting on how some
patients became extremely distressed the more accurate their understanding of
reality was, he remarked that patients ‘assist like helpless spectators of the collapse
of what is most precious in themselves, that is their moral freedom as well as their
intellectual faculties’ (Parant, 1888, p. 223). Like Dagonet, he thus believed that
preservation of awareness did not entail the preservation of free will and hence did
not entail legal responsibility for criminal acts.
1.3.2 British views

In nineteenth century Britain, the concept of awareness or insight in mental illness
was likewise a subject of debate. Interest, however, seemed to focus predominantly on
the narrower notion of awareness or consciousness of mental operations (Mercier,
1892) (akin to Despine’s ‘conscience personelle’). In this context, discussions were con-
cerned with examining the nature of conscious and unconscious mental processes
from physiological and philosophical perspectives (Davies, 1873; Ireland, 1875).
The wider concept of awareness of or insight into mental illness itself and the
effects of this on mental faculties did not appear to figure as significantly in debates
as it did in French psychiatry at that time. Instead, occasional reference to the con-
cept can be found in the clinical observations of alienists in their descriptions of
various forms of insanities (Bucknill & Tuke, 1858). Prichard (1835), for example,
concurring with Georget whom he cited, noted that insane patients were fully con-
vinced of their perfect sanity, ‘yet, as the same author observes [Georget], there are
some patients who are well aware of the disorder of their thoughts or of their affec-
tions, and who are deeply affected at not having sufficient strength of will to
repress it’ (Prichard, 1835, p. 121).
Some years later, Maudsley (1895) expressed considerable scepticism towards
the importance and role placed on consciousness in relation to mental function.
He stated:
it has been very difficult to persuade speculative psychologists who elaborate webs of philosophy
out of their own consciousness that consciousness has nothing to do with the actual work of
mental function; that it is the adjunct not the energy at work; not the agent in the process, but
the light which lightens a small part of it … we may put consciousness aside then when we are
considering the nature of the mechanism and the manner of its work …
Maudsley (1895, p. 8)
He reiterated this several years later: ‘consciousness is the dependent phenomenon

or so-called epiphenomena …’ (Maudsley, 1916, p. 7), a view stated earlier also by
Mercier (1892).
Maudsley’s conception of insanity precluded the possibility of insight or proper
judgement concerning the nature of the mental derangement on the part of the
patient. The insane patient, whose mental functions were deranged, became alien-
ated from himself, and, ‘he is now so self-regarding a self as to be incapable of right
regard to the notself …’ (Maudsley, 1895, p. 1). Whilst clinically the line between
sanity and insanity could not be well demarcated (Maudsley, 1885), in functional
terms, Maudsley drew a strict line between the sane and insane aspects of the
mind, with no real communication or exchange between them. According to him,
the sane man was incapable of judging precisely the behaviours and experiences of
an insane man (which carried implications for determining legal responsibility for
criminal acts). In the same way, patients with partial insanity could not judge with
their sane mental functions the phenomena produced by their insane mental func-
tions. As he said: ‘… each self thinks its own thinks or things – that is, thinks its own
world; the true self, or what remains of it, perceives the world as it looks to the sane
persons, and the morbid self or double perceives it as a strange and hostile world’
(Maudsley, 1895, p. 304). This conception of insanity very much echoes the views
at that time on double consciousness in the narrow sense. This was the view that
distinct mental states in the one individual, e.g. drunk versus sober, sleeping versus
awake, insane versus sane, could, independently, be aware of, judge and remember
such mental states but would have no recollection of, or communication with, the
different states (Azam, 1892). Importantly, however, like Despine (1875) and ante-
dating Lewis (1934) (see below), Maudsley did not believe it was possible for an
insane mind to make a rational judgement concerning its derangement.
The question of the role and state of consciousness in insanity continued troub-
ling writers well into the twentieth century. For example, Claye Shaw (1909), echo-
ing many of Maudsley’s views on consciousness, nevertheless, placed greater
importance on the notion in relation to mental illness, particularly again with
respect to determining legal responsibility. He suggested that the poor recall of
events shown by patients with acute mental illness was due to altered conscious-
ness or awareness at the time. Such changes in consciousness often may be subtle
and difficult to discern, because, he argued, ‘there are in reality as many forms of
consciousness as there are different mental states’ (Shaw, 1909, p. 408). However,
linking consciousness to emotional tone he went on to postulate that one way of
recognising altered consciousness in mental illness was by the dissonance or incon-
gruence between patients’ thoughts and their apparent emotional state: ‘there
is evidence that both in dream states and in insanity the emotional side of the
idea may be wanting, and this must have great effect on both memory and
consciousness … I have over and over again noticed that people with delusions of
a very depressed type do not show the emotional tone which should co-exist with
the delusions’ (Shaw, 1909, pp. 406–407). Once again, the implication behind
Shaw’s views is that the disordered or deranged mind, unable to attend to either
internal or external events, and hence unable to subsequently recall them, is unlikely
to be capable of forming ‘correct’ or sane judgements concerning the nature of
morbid pathology.
The notion of insight in its broader sense as awareness of mental illness rather
than consciousness of mental processes was not, however, debated as widely and
explicitly as in nineteenth century French psychiatry until Aubrey Lewis (1934)
offered his exploration of the concept. Pointing to the confusion due to the differ-
ent meanings given to ‘insight’ within and outwith psychiatry (including Gestalt
and psychoanalytic psychology), he suggested his own definition of insight as
‘a correct attitude to a morbid change in oneself ’. He then proceeded to examine in
turn the meaning of the individual terms within this definition and highlighted
some of the problems inherent to the definition of underlying concepts such as
‘normality’, ‘mental illness’ and ‘attitude’. Consequently, he pointed out, this made
the meaning or understanding of insight itself complicated. Like some of the earl-
ier alienists, notably Parant and Jaspers, in his conceptualisation of insight, Lewis
distinguished between awareness of change and judgement of change, both being
necessary components of insight. Thus, in order to have an ‘attitude’ to the change
in oneself, the patient must first become aware of the change, before secondarily,
forming a judgement of this. He considered the notion of awareness in more detail

and went on to suggest that awareness itself could be further subdivided into:
firstly, awareness based on primary or immediate perceptions, e.g. becoming aware
of feeling different and unpleasant in depersonalisation, that is, the direct feeling
that there is a change and secondly, awareness based on secondary data, e.g.
becoming aware of a change in capacity to function, making mistakes, that is, the
feeling that there must be a change. In other words, without elaborating on this
explicitly, Lewis conceptualised insight as a complex of qualitatively different types
of judgements, or rather, judgements based on different types of ‘information’.
The final judgement then referred to the patient’s attribution of the experienced
changes in terms of whether the patient believed they represented illness or some
other explanations such as satanic possession, etc.
Like Maudsley, though on slightly different grounds, Lewis believed that it was
not possible for patients with mental illness to attain complete insight, insofar as
the definition of insight related to the attitude of a non-affected individual. He stated
that:
In any mental disorder, whether mild or severe, continued or brief, alien or comprehensible, it
is with his whole disordered mind that the patient contemplates his state or his individual
symptoms and in this disorder there are disturbances which are different from the healthy
function either in degree, combination or kind … always there will be a disturbance which
makes it impossible for the patient to look at his data and judge them as we, the dispassionate,
presumably healthy outsiders do. His judgements and attitude can therefore never be the
same as ours because his data are different, and his machine for judging is different in some
respects.
Lewis (1934, p. 343)
Lewis based his argument on his conceptualisation of insight which by his definition,
in terms of ‘correct’, included the comparison of view with a non-affected indi-
vidual. Thus, there were two reasons why a mentally ill patient could not have
full insight. Firstly, the mental illness itself caused disturbances in the subjective
self which could not possibly be appreciated by an outsider (and therefore a con-
cordance could not be achieved). Secondly, the tools with which the ill patient
could make judgements (‘disordered mind’) were themselves affected by the men-
tal illness and therefore could not make a just assessment. Interestingly, Lewis
made it explicit, including in his explanation of ‘correct attitude’, that the clinical
concept of insight related importantly to the judgement made by an unaffected
observer and hence represented, to some extent, an interaction between the latter
and the patient. The conceptualisation of insight in these terms, extending to
a complex of judgements between individuals, was thus becoming yet more
intricate.
1.3.3 German views

Early and middle nineteenth century German psychiatric writing likewise shows
references to insight into madness in the form of clinical observations made by
alienists (see review by Pick (1882)) and, as elsewhere at the time, the concept itself
was not yet clearly formed. In the context of medico-legal perspectives, Hoffbauer’s
(1808/1827) influential book refers to mad patients being able to judge their
behaviours without being able to suppress their passions or to resist the violent
acts into which they are forced. Debates, however, examining specifically the con-
cept of insight into madness were not prominent. This was pointed out by Arnold
Pick who himself devoted a lengthy article to the subject in 1882. He focused pre-
dominantly on a historical account describing and quoting observations made
by earlier alienists (French, German and English) on the presence of awareness or
some degree of awareness in patients with different mental disorders and also
included his own clinical observations. He did not provide a historical analysis of
the conceptualisation of awareness or insight into mental illness but did make
some interesting and important clinical and conceptual points.
In terms of the clinical, Pick emphasised that in most mental disorders (includ-
ing mania, melancholia, obsessive compulsive disorders, psychoses, dementia,
alcohol abuse, etc.) patients could show some awareness of their illness though this
varied in extent and type according to the mental disorder affecting them. In add-
ition, he noticed that in general, patients whose mental illnesses developed grad-
ually over time seemed to show more awareness of their illness than those whose
illnesses developed acutely. In terms of the conceptual, Pick explicitly defined his
understanding of the notion of ‘awareness of illness’ which became influential in
the conceptualisation of insight in later German psychiatry. Interestingly, he con-
ceived awareness of illness (‘Krankheitsbewußtsein’) as the broad, general concept
which encompassed all the phenomena relating to the feelings or recognition
experienced by patients concerning the morbidity of their psychic events. He fur-
ther subdivided this broad concept into two distinct components, namely, aware-
ness of feeling ill (‘Krankheitsgefühl’) and insight into illness (‘Krankheitseinsicht’).
The former he viewed as an alteration in the feeling or sense of well-being. As such,
he viewed this as a disturbance of the ‘Gemeingefühl’. This term referred to the old
distinction made between skin senses, i.e. touch, temperature, pressure, etc. and
the senses left after these were separated off [common feeling or Gemeingefühl]
and hence included pain, well-being, pleasure, fatigue, etc. (Berrios, 1996). The
latter, i.e. insight into illness, Pick defined as the product of reason or reflection.
Thus, patients with some awareness of illness (‘Krankheitsbewußtsein’) could have
either awareness of feeling ill, or insight into illness or they could have both. Pick
further observed that the relationship between feeling of illness and insight into ill-
ness was not straightforward. Whilst many patients with awareness of feeling ill did
progress to developing insight into their illness, other patients, notably those with
hypochondriacal conditions, had marked feelings of being ill and yet had no
insight into their illness (Pick, 1882).
Whilst agreeing with Pick’s distinction between awareness of feeling ill and
insight into illness, Arndt (1905) pointed out that awareness of feeling ill and the
reflective insight into illness were, in fact, interdependent since the ‘feeling’ had to
depend on some knowledge of bodily change. Likewise, the ‘knowledge’ of change
had to depend on some feeling of change. He thus suggested that the distinction
between ‘awareness of feeling ill’ and ‘insight into illness’ did not lie in the differ-
ence between ‘feeling’ in the former and ‘reflection’ in the latter but was based on
the difference in clarity with which the insight is experienced. Patients whose
awareness of illness was based on the feeling of being ill experienced insight into
their illness with much greater clarity and self-involvement. On the other hand,
patients whose awareness of illness was based on rational or reflective insight into
their illness experienced this with less clarity and often clouded by suspicion. In
other words, Arndt emphasised the importance of the experiential aspect of
insight, which, interestingly, shares similarities with later psychoanalytic perspec-
tives (Chapter 2). Arndt went on to analyse what he viewed as the necessary elem-
ents in the development of insight of illness, namely, the feeling of illness,
reasonable judgement and past experience. Each of these elements could be dis-
turbed, in different ways, in patients with mental illness. For example, he pointed
out that in mental disorders the feeling of illness might not be present in the con-
ventional sense. Patients could feel different and sometimes this feeling resonated
with psychological states (e.g. guilt feelings and home sickness) but the feeling
did not have to relate to ‘illness’ in the normal sense. Consequently, experienced
changes could be attributed to other non-illness factors (e.g. external influences)
and hence, almost by definition, patients with mental illness would lack this elem-
ent constituting insight into their illness. Arndt (1905) also speculated on the
underlying processes that might be disturbed in patients with mental illness who
showed impaired insight. In this vein, he suggested a role for attention, memory,
capacity for observation, judgement, conceptual thinking and education.
Following the distinction made and terminology used by Pick concerning
awareness into illness (‘Krankheitsbewußtsein’), Aschaffenburg (1915), concen-
trated from a purely clinical perspective, on examining each suggested component,
namely, the feeling of illness (‘Krankheitsgefühl’) (defined as vague fears and uncer-
tainties) and insight into illness (‘Krankheitseinsicht’) (defined as understanding
the nature and severity of the illness) and the relationship between them. On the
basis of clinical observations, he pointed out, as had Pick and Arndt earlier, that
there was not a direct progression from awareness of feeling ill to insight into being ill
and indeed there was often a discrepancy or mismatch between patients’ subjective
feeling of illness and their insight into illness. Thus, patients could have no feeling
of illness and yet have good insight into the fact that they were ill, as in some cases
of syphilis. Likewise, patients could have intense feelings of being ill and yet have
little insight into their illness, e.g. patients with various neuroses or hypochondria-
cal illnesses. He distinguished between the awareness of feeling ill in patients with
physical and with mental illnesses. In the former, this developed into awareness
of illness when patients clarified and formulated such feelings into fears of the
unknown, fears of pain, operations, etc. In the latter, i.e. awareness of feeling ill in
patients with mental illness, this was often the first sign of their illness itself, such
as depressive symptoms. In contrast to the case in physical illness, as such feelings
were ‘clarified’ and judged, then the experience of feeling of illness itself tended to
reduce as this was superseded by the pathological ‘rationalisation’ of the illness
process itself (Aschaffenburg, 1915, pp. 367–369).
By extending his observations of these components of insight into patients with
different mental disorders, he was able to suggest different possible mechanisms
that could affect patients’ judgements of their illness. Like Jaspers (see below), he
emphasised the difficulties in clinically determining patients’ insight and amongst
reasons for this, included his observation that insight as a judgement evolved over
time and that different morbid symptoms and features of the illness required dif-
ferent amounts of time to judge. In addition, he was clear about discrepancies
between insight as expressed by patients and their behaviours which were counter
to their utterances, for example, compulsions in a patient who had insight into his
illness (Aschaffenburg, 1915, pp. 369–371).
The concept of insight in terms of its nature, its diagnostic and predictive sig-
nificance, did not seem to interest Kraepelin (or Bleuler) a great deal. Kraepelin
referred to the notion under ‘judgement’: ‘what always surprises the observer anew
is the quiet complacency with which the most nonsensical ideas can be uttered by
them and the most incomprehensive actions carried out’ (Kraepelin, 1913/1919,
p. 25). He observed that some patients showed awareness of the morbidity of their
state early in the disease, but that this left them as the disease progressed: ‘the
patients often have a distinct feeling of the profound change which has taken place
in them. They complain that they are “dark in the head”, not free, often in confu-
sion, no longer clear, and that they have “cloud thoughts” … understanding of the
disease disappears fairly rapidly as the malady progresses’ (Kraepelin, 1913/1919,
pp. 25–26). Beyond subsequently commenting that ‘a certain insight into their dis-
eased state is frequently present’ in patients with the catatonic form of dementia
praecox (Kraepelin, 1913/1919, p. 150), and that, in contrast to patients with
dementia praecox, patients with manic-depressive psychosis had ‘more tendency
to, and ability for, the observation of self, to painful dissection of their psychic state’
(Kraepelin, 1913/1919, p. 264), Kraepelin did not further elaborate on the concept.
It was Karl Jaspers who focused specifically on the concept of insight into men-
tal illness and indeed the concept appeared to develop more in depth and detail
with successive editions of his ‘General Psychopathology’ (1913 (1st edition) to 1959
(7th edition)). From a combination of both clinical and psychological/philosophical
perspectives, he explored the concept of insight in several different ways, breaking
this up in terms of awareness of mental processes (consciousness in the narrow
sense), awareness of the sense and activities of the self and attitudes towards men-
tal illness. His conception of insight in these component forms emphasised a close
and bi-directional relationship between the personality judging the mental phe-
nomena affecting him and the manifestation of the psychopathology itself. In
other words, and crucially, it was not only that patients became aware and judged
the mental symptoms and illness that affected them, but the expression of the
mental symptoms themselves was affected by the awareness and judgements made
by the patients. He thus believed that it was essential to study patients’ under-
standing or insight into what was happening to them: ‘Patients’ self-observation,
their attentiveness to their abnormal experience and the processing of their obser-
vations in the form of a psychological judgement that can communicate to us their
inner life, is one of the most important sources of knowledge in regard to morbid
psychic life’ (Jaspers, 1948, p. 350, my translation). On the basis of his clinical
observations, Jaspers described various stages in the manifestation of patients’
awareness. He observed that, in the early stages of their psychotic illness, patients
became bewildered, this being an understandable reaction to the new experiences
they were undergoing. Awareness here, he contended, was related to the multitude of
different sensations they were experiencing and as such was not really a judgement as
a whole (akin to the awareness of immediate data in Lewis above). As the illness pro-
gressed, patients tried to make sense of their experiences, for example, by elaborating
delusional systems. Thereafter, Jaspers described how, when the illness produced
changes in personality, a patient’s attitude to the illness became less understandable to
others as he/she could appear indifferent or passive to the most frightening delusions.
Jaspers distinguished between these stages of changes which referred to aware-
ness of the content of patients’ experiences and insight itself which referred to
judgements made by the patient concerning their illness and hence involved the
relationship between such awareness and the self. Influenced by Pick, though con-
ceptualising the structure of insight slightly differently, he made a distinction, in
the latter judgements, between awareness of illness (‘Krankheitsbewußtsein’) and
insight proper (‘Krankheitseinsicht’). The former referred to the experience of feel-
ing ill and changed but without this awareness reaching all symptoms or the illness
as a whole. The latter, however, included an objectively correct assessment of the
nature and severity of the illness affecting the individual both as a whole and of
each individual symptom (Jaspers, 1948, pp. 349–350). Jaspers did qualify this
requirement of objectively correct judgement as one that would be made by an

average, healthy individual from the same cultural background as the patient. In fact,
Jaspers emphasised that such judgements depended on the intelligence, background
and culture of the individual. Indeed, because these judgements are inherently a part
of the personality make-up, then in the case of patients with intelligence below a cer-
tain level, e.g. idiocy, it would be more appropriate to consider loss of personality
rather than loss of awareness as the feature in their lack of knowledge of themselves.
Jaspers also observed that while transient insight may occur during acute
psychoses, there was no lasting or complete insight. He insisted that where insight
persisted, the patient was more likely to be suffering from a personality disorder
(Psychopathie) than a psychosis. In patients who recovered from the psychotic
state, Jaspers made a distinction between psychoses such as mania and alcoholic
hallucinosis where the patients were able to look back on their experiences with
‘complete’ insight, and a psychosis such as schizophrenia where they did not show
full insight. He reported the latter patients as being unable to talk freely about the
contents of their experiences, becoming overtly affected when pressed to do so, and
occasionally maintaining some features of their illnesses. He further described
patients with chronic psychotic states who, from their verbal contents, often
appeared to have full insight, yet in fact such verbal contents would turn out to be
learnt phrases and meaningless to the patients themselves.
In terms of assessing patients’ insight, Jaspers was clear that there were limits to
the extent to which outsiders could hope to understand patients’ attitudes to their
illness. He formulated this by stating that it was easier to assess patients’ objective
knowledge (‘objektives Wissen’), that is, their ability to understand and apply med-
ical knowledge to themselves, than their comprehending appropriation (‘verste-
hendes Aneignen’) of it. The latter understanding, Jaspers claimed, was intrinsically
linked with the patients’ selves, and hence could not be divorced from the know-
ledge of self-existence itself.
In a similar vein to Jaspers, in terms of conceiving insight as a process of aware-
ness of change in the self and the environment, albeit not using the term explicitly,
Conrad (1958) depicted these experiential changes in patients in his long-term
observations around the development and progression of the psychotic state. He
named the early stage of the schizophrenic illness the ‘trema’. During this stage, he
noted that patients found it difficult to express their feelings and experiences; some
would talk about fear, tension, anxiety and anticipation, while others would
describe feelings of guilt and helplessness. Conrad believed that the common theme
was a feeling of oppression, an awareness that something was not right, and a sense
of restriction of one’s freedom. During the next stage of illness, the ‘apophany’,
patients attributed meaning to feelings and experiences; for example, when in the
state of ‘anastrophe’, patients believed themselves to be the centre of the world.
Conrad described further stages during which destructive processes were followed
by partial resolution as residual schizophrenic effects persisted, and postulated that
schizophrenia was an illness affecting the higher mental functions which differen-
tiate humans from animals. Thus, it affected the whole self-concept and, in particu-
lar, the ability of the individual to effect the normal transition from looking at
oneself from within to looking at oneself from the outside, by the eyes of the world.
1.4 Conclusion
The concept of insight into mental illness emerged around the middle of the nine-
teenth century as an independent phenomenon that could be explored in patients.
This can be understood in the contexts of: (i) general increased interest in individu-
ality and self-reflection at this time, together with the development of concepts
such as introspection, apperception and ‘verstehen’ legitimising subjectivity as
an area of enquiry and (ii) changing views on the nature of mental illness and the
conceptualisation of partial insanities, opening up a space in which it became pos-
sible to conceive insight into madness. The partial insanity debates were, in turn,
influenced by the empirical observations of alienists, the medico-legal challenges
of the courts and the development of faculty psychology including phrenology.
In the early part of the nineteenth century, the concept of insight into mental ill-
ness was not yet clearly formed and patients were simply observed as having or not
having awareness of their illness. Awareness at this point seemed to refer variously
to feelings or judgements. By the middle of the nineteenth century debates specifically
addressed at the concept of insight were taking place, particularly in France. In the
context of these discussions, where insight was explored in relation to mental dis-
orders, to the notion of self, to mental faculties and to the issue of legal responsibil-
ity for criminal acts, the concept of insight began to develop a structure as attempts
were made to define and distinguish between independent mental processes
(Falret, 1866; Billod, 1870; Morel, 1870). Clinically, insight was also becoming
more prominent as a feature to be examined in different clinical groups and men-
tal disorders (Billod, 1870; Morel, 1870), as a criterion distinguishing between clin-
ical disorders (Ritti, 1879) and as a prognostic variable (Billod, 1870).
Towards the end of the nineteenth century, insight into mental illness seemed to
refer to two main concepts. Firstly, there was the narrower concept of awareness or
consciousness of mental operations (Despine, 1875; Maudsley, 1895). Alienists
holding this concept generally believed that whilst patients could have awareness
of particular mental processes, this did not extend to an awareness of such
processes being morbid. Secondly, there was the wider concept of insight which
included both an awareness of mental phenomena together with some awareness
of the self as an individual but, in addition, a judgement made by patients
concerning the illness affecting them (Dagonet, 1881; Billod, 1882; Pick, 1882;
Parant, 1888). Alienists conceiving insight in this broad way tended to believe that
patients could have insight and even different degrees of insight into their illness.
Part of the problem in attempting to define the emerging structure of insight, how-
ever, is the difficulty involved in trying to clarify the nature of the constituent
components. Whilst some alienists could conceive clear distinctions between
awareness, feeling and judgement, for others those demarcations were blurred or
did not exist. In turn, such disparities seemed to be based on different understand-
ing of the nature of, and relationship between, mental processes themselves and
their connection or otherwise to brain processes. Nevertheless, a rough structure
can begin to be identified with components based on distinctions between differ-
ent types of awareness (Dagonet, 1881), between different types of judgements
(Billod, 1882), between feelings and reason (Pick, 1882) and between subjective
utterances and observed behaviours (Pick, 1882; Parant, 1888).
After the turn of the century, the broader conceptualisation of insight into men-
tal illness seemed to hold. However, this became more complicated in terms of
determining individual components, e.g. contribution of intelligence, culture, past
experience, capacity for observation, memory, etc. (Arndt, 1905; Jaspers, 1913) as
well as defining the boundaries of such a structure, e.g. extent of knowledge
demanded, level of concordance needed with the unaffected individual (Lewis,
1934), both from a theoretical and the clinical perspective. In addition, qualitative
differences in insight between patients with different types of mental disorders
were beginning to be identified (Arndt, 1905; Aschaffenburg, 1915). This, together
with the unresolved issues concerning the nature of the components of insight,
further compounded the complexity of the insight structure. Nonetheless, insight
conceived as an awareness of change together with some judgement made of this
change has remained the core of the theoretical concept ever since.
2
The psychological perspective: Gestalt,

cognitive and psychoanalytic
A significant influence on both the conceptualisation of insight in psychiatry as

well as on its empirical assessment, particularly within the neurosciences (e.g. in
specific neurological deficits, neuropsychological impairments, dementias, etc.),
has come from psychology. Such influence has, in the main, arisen predominantly
from two psychological schools of thought, namely, Gestalt psychology (and
Gestalt-influenced cognitive psychology) and the psychoanalytic psychologies.
Whilst it is not the place here to explore the history of psychology as a discipline, it
may be useful to very briefly contextualise the origin of the above schools of think-
ing. Neuropsychological approaches to the conceptualisations of awareness will be
dealt with in Chapters 4 and 5.
The previous chapter highlighted the contribution made to the conceptualisa-
tion of insight as a clinical phenomenon by, amongst other things, the emergence
of or focus on various psychological concepts during the eighteenth and nineteenth
centuries. Amongst these, the notions of Verstehen, introspection, self-reflection,
apperception, etc. were particularly important and related in different ways to
attempts at describing and understanding the subjectivity of inner experiences.
Towards the end of the nineteenth century, psychology was concerned with the sci-
entific study of the contents or ‘facts’ of consciousness. These facts of conscious-
ness ranged from the most basic or ‘atomic’ units of analysis, such as sensation or
attention to more complex units such as perceptions, apperceptions or memory,
which were understood as being formed from the combination of the atomic units
through the laws of associationism. All these facts of consciousness were accessible
to the individual and scientist by means of introspection. Such facts of conscious-
ness were viewed as reflecting in a direct way both the external world and the brain.
In other words, there was envisaged a structural correspondence or relationship
between the elements making up the external world and the elements forming
the contents of consciousness. This structural relationship, furthermore, could
be defined and studied by means of psychophysical laws. Wilhelm Wundt
(1832–1920) was the major figure in the development of this scientific or physio-
logical psychology and, together with the Würzburg School, was important in
formulating such psychophysical laws (Wundt, 1886/1880).
34
35 The psychological perspective
At the turn of the century, there arose, independently, various challenges to this
form of scientific psychology. Whilst all seemed to argue against the validity of thus
analysing the contents of consciousness, the nature of their objections was very
different. Behaviourism rejected completely the notion that consciousness could be
a valid object of inquiry and turned instead to the study of relationships between
events that could be ‘objectively’ observed and measured. Introspection was con-
ceived as too subjective and hence ‘inaccurate’ and, consequently, consciousness
was placed in a metaphorical black box whilst psychological studies focused on
correlations between its inputs (experimental stimuli) and outputs (behavioural
or physiological responses). Gestalt psychology, on the other hand, challenged the
way in which the ‘facts’ of consciousness were analysed. Specifically, the Gestalt
psychologists argued against the mechanistic structural correspondence that was
conceived between the external world, the contents of consciousness and the brain
itself. Instead, they put forward a functional correspondence that depended on the
mind responding not just to the aggregated constituents of objects but also to the
functional relations between such constituents in the formation of the object as a
whole. In other words, the whole was viewed as different from the sum of its parts.
Brain processes reflected this capacity to integrate functional interrelationships in
order to produce the experience of the whole in the mind of the individual. From
a different perspective again was the objection held by psychoanalytic psycholo-
gists. They claimed that the validity of using the contents of consciousness as
the object of inquiry was compromised because such contents were inherently
unstable and distorted by unconscious mental processes. It thus made more sense,
the psychoanalysts argued, to focus instead, by means of interpretation and other
strategies, on such unconscious mental processes as the objects of psychological
inquiry.
For the purposes here, it is with the latter two schools of psychological thought
that insight is explored. The chapter thus first looks at the notion of insight as
developed by the Gestalt psychologists and by the Gestalt influenced but contem-
porary cognitive psychologists. Then, the notion of insight as conceived within the
psychoanalytical framework is examined together with its perceived role in psy-
chotherapeutic processes. The aim in briefly exploring these psychological per-
spectives on insight is two-fold. Firstly, as already mentioned, both schools of
thought make an important contribution to the conceptualisation and assessment
of insight in clinical psychiatry and neuropsychiatry. Secondly, there are also sig-
nificant differences between the ways in which insight is conceptualised from these
perspectives and from within psychiatry in general. Such differences are important
to highlight in order to help clarify some of the confusion that is present around
the terms and meanings relating to insight in empirical studies. The nature of these
and other differences, evident in the conceptualisation of insight, together with the
implications these carry for understanding results of empirical work and for deter-
mining a structure for insight will be discussed in the second part of this book.
2.1 The concept of insight in Gestalt psychology and cognitive psychology
One of the main principles underlying Gestalt theory was that the whole was
greater than (and different from) the sum of its parts. This idea appeared to be
originally articulated by Ehrenfels (1890), a member of the Würzburg School.
Using the example of a melody (the whole) consisting of separate tones (individ-
ual elements), he argued that even when the tones were played in a different key,
the melody could still be recognised as a particular melody but that when the same
tones were played in a different sequence the melody was no longer recognisable.
Thus, it was not just the sum of the individual elements (tones) that was important
in the perception of the whole (melody) but the relations of such elements to each
other (i.e. their organisation) that was important in the perception of the whole
melody. He coined the term ‘Gestaltsqualitäten’ (qualities of the Gestalt (Gestalt is
variously translated as ‘form’, ‘shape’ or ‘configuration’ and simply refers to a par-
ticular whole)) to specify that wholes had such qualities. These were not perceived
simply in terms of the sum of their elements but it was the way in which the elem-
ents were organised, that gave the qualitative aspect to the whole and which
helped to determine a particular experience or perception of the whole. This
notion was taken up and developed by Max Wertheimer, the Principal Founder of
Gestalt Psychology, and by Wolfgang Köhler and Kurt Koffka, his younger colleagues.
Much of the early work in Gestalt psychology was focused on the area of percep-
tion but subsequently the Gestalt principles were extended to other areas of psych-
ology, particularly to learning, problem-solving and developmental psychology.
Within Gestalt theory, the concept of insight has carried a very specific meaning
which contrasts, both in terms of content and specificity, to the way in which
insight has been conceptualised in general psychiatry (Chapter 3) and in neuro-
logical states (Chapters 4 and 5). Its essence lies in the grasp or understanding an
individual (or animal) obtains of a specific situation in a particular way. Thus, it is
not just understanding of a situation or problem but it is a ‘genuine’ or ‘productive’
understanding that is based on appreciation of the functional inner relatedness of
the parts of the structure of a situation (Wertheimer, 1945/1961). Köhler applied
this concept to the study of intelligent behaviour in chimpanzees. He asked the
question whether chimpanzees were capable of behaving with insight, i.e. whether
they could find solutions to certain problems that were based on insight rather
than on chance or trial-and-error learning. In order to determine this, he devised
various tasks for the apes whose solutions were not straightforward or direct but
depended on the ape taking account of the task as a whole in terms of available
components and their relationships with each other. For example, one such task
involved placing fruit within sight but just out of reach of the chimpanzee. There
was a small stick in the cage with the animal (at this stage the apes were familiar
with using sticks to help them reach fruit) but this was not long enough to reach
the fruit. Outside the cage there was placed a longer stick which was out of reach
of the animal but could be pulled within reach by means of the smaller stick. In turn
the longer stick could then be used to reach the fruit (Köhler, 1924/1957). These
sorts of tasks thus, argued Köhler, contained components which, if considered
individually, could be seen as meaningless or irrelevant, or even contradictory to
the structure of the solution as a whole. The criterion of insight, he went on to
specify, was ‘the appearance of a complete solution with reference to the whole lay-
out of the field’ (Köhler, 1924/1957, p. 164). It was only by consideration of the
structure of the situation that a solution could be viewed as insightful. He distin-
guished between animal behaviours that led to solutions by chance and behaviours
that resulted in solutions by insight. In the former, the chimpanzee’s actions would
be haphazard and consist of a number of single separate fractions which after some
time might lead to the solution. By contrast, tasks that were solved by insight were
characterised by behaviours which showed a ‘smooth, continuous course, sharply
divided by an abrupt break from the preceding (non-insightful) behaviour … this
process as a whole corresponds to the structure of the situation, to the relation of
its parts to one another’ (Köhler, 1924/1957, pp. 163–164). In psychological terms,
Köhler interpreted such behaviours as indicating ‘the sudden occurrence of per-
fectly clear and definite solutions’ (Köhler, 1924/1957, p. 207), thereby, reflecting
the presence of insight in the animal.
In Gestalt terms, the notion of insight was thus conceived as a reorganisation of
a particular situation through an understanding of the functional relationships
between relevant component parts. (For example, sticks could be perceived as
immaterial or as playthings or as specific tools according to the demands of a par-
ticular situation.) Furthermore, again in line with some of the early Gestalt work,
Köhler understood this reorganisation to involve a perceptual process. Hence:
insight of the chimpanzee shows itself to be principally determined by his optical apprehension
of the situation; at times he even starts solving problems from a too visual point of view, and in
many cases in which the chimpanzee stops acting with insight, it may have been simply that the
structure of the situation was too much for his visual grasp.
Köhler (1924/1957, p. 228 original emphasis)
Koffka (1935/1963) maintained that Köhler was offering insight simply as a descrip-
tion rather than an explanation in itself. However, Köhler did attempt to provide
some explanation based on a modification of associationism. Thus, rather than
relations between things being perceived by means of a mechanical association
(i.e. links understood when there was frequent following of each other or occurring
together), they could be perceived by means of a functional association, i.e. ‘based
on the properties of these things themselves’ (Köhler, 1924/1957, p. 189).
There have since been numerous criticisms directed at Köhler’s interpretation
of the animals’ behaviours as ‘insight’ (see Koffka, 1925/1980 for a comprehensive
review) and indeed many of the issues raised have been echoed in subsequent debates
in relation to more sophisticated cognitive experiments (see below). Nevertheless,
this definition of insight, as a form of intelligent behaviour or thought charac-
terised by a sudden, rapid, smooth and directed process through which a particu-
lar objective is attained, has remained at the core of the Gestalt and cognitive
psychological conceptualisations of insight.
In an important work, published posthumously, Wertheimer (1945/1961)
applied similar Gestalt principles to the study of learning and problem-solving in
human beings. He attempted to analyse the processes that took place during
insightful or ‘productive’ thinking. Distinguishing between understanding that was
based on such productive thinking and understanding based on blind repetition or
learning by rote, he showed in a number of experiments that only the former could
result in subjects applying their knowledge to a variety of different, albeit related,
problems. Indeed, he criticised the teaching of children by drill which, he argued,
was counterproductive to thinking and induced habits of sheer mechanised action
rather than leading to a true grasp of problems. Like Köhler, he emphasised the
need for the subject to grasp the structure of the whole problem in terms of the
inner relatedness of its parts. In this sense, he described the process of attaining
insight as a top-down rather than bottom-up procedure. Attempting to break
down such operations, Wertheimer focused repeatedly on the demands made by
the structure of the task/problem. He suggested a process which was:
not just a sum of several steps, not an aggregate of several operations, but the growth of one line
of thinking out of the gaps in the situation, out of the structural troubles … it is not a process
that moves from pieces to an aggregate, from below to above, but from above to below, from the
nature of the structural trouble to the concrete steps.
Wertheimer (1945/1961, pp. 49–50)
Like Köhler, Wertheimer suggested that the processes underlying productive or

insightful thinking could be considered in terms of modified associationistic laws
which relied on functional rather than mechanical relationships. He suggested that
such processes involved operations of dividing the whole into sub-wholes (though
continuing to perceive how the sub-wholes fit together) and described such oper-
ations as grouping, reorganisation and structurisation.
Wertheimer’s studies with human beings (often children) allowed him to access
subjective experiences during learning and problem-solving exercises (e.g. working
out the area of a parallelogram) and these also helped to distinguish between solutions
that were insightful and solutions that occurred by chance or trial and error. Thus, he
described subjects expressing the process of ‘seeing the light … (the problem) sud-
denly became transparently clear, meaningful, in the realisation of the inner structure,
the inner requirements of the process’ (Wertheimer, 1945/1961, p. 67). This subjective
sense of clarity and new understanding together with a feeling of satisfaction has
continued to characterise the phenomenon of insight in this area of psychology.
Likewise concentrating on analysing processes underlying problem-solving,
Karl Duncker (1945) further developed Wertheimer’s ideas on restructuring as a
necessary condition for insight. Whilst Gestalt thinking explicitly objected to the
prevailing associationistic explanations underlying thinking and behaviours, the
proposed alternative framed in terms of functional associations, restructuring and
reorganising of perceptual or cognitive fields has been, and continues to be, criti-
cised for its lack of a clear theoretical and explanatory basis (e.g. Osgood, 1964;
Ohlsson, 1984a, b; Isaak & Just, 1995; Mayer, 1995). Nonetheless Duncker (1945),
in his important work on insight and problem-solving, attempted to provide
a clearer and more detailed account of possible processes or stages underlying
insightful problem-solving. He proposed that insight into a problem depended
crucially on restructuring of the problem. In turn, this restructuring could occur in
two main ways. Firstly, the functional goal (i.e. the general purpose) of the prob-
lem could be redefined (he called this process a suggestion from above), and,
secondly, the function of the components of the problem could be reformulated
(suggestion from below) such that the original information presented was defined
in a different way. He also examined possible processes underlying the reasons why
subjects might not achieve a problem solution, i.e. why restructuring might not
occur. He proposed that a subject’s past experience could have a detrimental effect
on such restructuring because this could force a particular mode of thinking and
detract from considering novel approaches. Thus, past experience could become
an actual block to the individual and Duncker termed this functional fixedness.
Duncker’s ideas, his experimental problems and proposed psychological processes
have been extremely influential in the approaches taken by cognitive psychologists
in more recent studies on insight (Sternberg & Davidson, 1995).
It is of interest that the concept of insight as developed by the early Gestalt
psychologists and refined by later cognitive psychologists has been and continues
to be, despite its specificity, an area of much debate and dispute. As is the case with the
ways in which insight is dealt with by the more clinical disciplines (see later), differ-
ences in views concerning the meaning of insight, its nature, its elicitation and its likely
underlying mechanisms/processes are also prevalent in the psychological disciplines.
These differences serve to highlight some of the complexities present around the con-
ceptualisation of insight and it is useful to examine briefly some of these issues in turn.
2.1.1 The meaning of insight

The meaning of insight, in terms of definition, characteristics and nature, has itself
been the source of much variability and often contradictory views (Hartmann,
1931; Bulbrook, 1932; Schooler et al., 1995). Most commonly, and following early
Gestalt views (Köhler, 1924/1957; Hartmann, 1931; Hutchinson, 1941), researchers
define insight very specifically, as ‘the sudden unexpected solution to a problem’ (e.g.
Schooler et al., 1995). The specificity, which contrasts with the more general defi-
nitions of insight in psychiatric usage (see next chapter), lies in several aspects of
this definition. Thus, the suddenness specifies an abrupt emergence of the solution
event (relating to behaviour or thought); the unexpectedness refers to the surprise
element of the event or change and the solution to a problem delineates the dis-
creteness of the event, implying both a particular task accomplished and a time-
limited episode. Differing views, however, have emerged in relation to these aspects
of the definition. In general, suddenness has been a relatively consistent defining
characteristic throughout as identified in early Gestalt psychology (e.g. Köhler,
1924/1957) and prominent in contemporary cognitive psychology (e.g. Davidson,
1995; Henley, 1999). Arguing against the concept of partial or gradual insight as
proffered by Alpert, Hartmann (1931) explicitly emphasised the importance of
suddenness, ‘where insight is not immediate or at least sudden it has lost its essen-
tial character’ (Hartmann, 1931, p. 248). (This definitional feature contrasts par-
ticularly with the general psychiatric notion of insight, the latter being conceived
in terms of knowledge of problems that develops gradually over unspecified
lengths of time.) On the other hand, amongst the cognitive psychologists there are
some dissenting views. For example, Weisberg (1995) argues against the view that
suddenness and unexpectedness, as manifestations of the Gestalt ‘Aha’ experience,
should be considered definitional criteria of insight. Part of the problem here,
however, relates to the fact that many of the offered definitions of insight incorp-
orate, to various extents, mixtures of theoretical, phenomenological/experiential
and explanatory notions. This then makes it difficult to tease out the specific refer-
ents of the individual components of definitions. Some definitions achieve partial
clarification by making certain distinctions. Smith (1995, p. 232) thus distin-
guishes between insight as an ‘understanding’ and an insight experience as the ‘sud-
den emergence of an idea into conscious awareness, the “Aha!” experience’. Gruber
(1995) distinguishes between insight as ‘problem-solving’, which includes the sud-
denness criterion, and insight as ‘understanding’ which focuses on knowledge or
self-knowledge (in the psychoanalytic sense) rather than the moment of its attain-
ment. Gick and Lockhart (1995) specify that suddenness and surprise relate only to
the affective and not to the cognitive component of insight. Others have used
descriptions of putative stages in the development of insight which partially sep-
arate out possible underlying processes and experiential descriptions occurring at
different stages (e.g. Hutchinson, 1941; Csikszentmihalyi & Sawyer, 1995; Seifert et al.,
1995, see below). The experiential aspects of insight, i.e. the subjective elements
have also carried various emphases in different definitions. For many, it has not been
particularly relevant (Köhler, 1924/1957; Weisberg, 1995) but others have specified
accompanying subjective experiences such as elation (Hutchinson, 1941), satisfaction
and triumph (Seifert et al., 1995) and delight, humour or chagrin (Gick & Lockhart,
1995). Interestingly, the question of whether the experiential aspects, in terms of
the sense of revelation and satisfaction, could occur independently of correct solu-
tions does not seem to have been explored. In other words, is it possible for sub-
jects to experience the sudden feeling of clarity and sense of enlightenment when
incorrectly solving a problem albeit under the impression it was correct? Clearly
the assumption is that the subjective experience of clarity and understanding has
to correspond intrinsically to a ‘correct’ appraisal of the problem or situation.
The specificity of insight in terms of referring to some form of problem-solving
has also tended to be held with relative consistency. (This level of specificity is
markedly in contrast to the notion of insight as conceived in psychiatric disorders.)
Nevertheless, some variability is found here as well. Seifert et al. (1995) state clearly
that insight is not restricted to problem-solving but includes knowledge about
the world and about oneself. They thus provide a broader theoretical definition
though they do limit this to problem-solving for empirical purposes. Similarly
Finke (1995), in discussions around creative insight, defines this as ‘an essential
process by which we come to make surprising discoveries and realisations, both
about real-world issues and problems, and about ourselves’ (Finke, 1995, p. 255).
This is a much wider conception of insight. Gruber (1995) whilst defining insight
as a moment or flash of enlightenment, at the same time, places this as ‘part of
coherent life’. Some view insight as a state of mind (e.g. Dominowski & Dallob,
1995) while others define it as a process made up of several stages (Davidson &
Sternberg, 1986; Ippolito & Tweney, 1995; Mayer, 1995).
Apart from the issue of specificity in regards to problem-solving, relating insight
to problem-solving itself is a fundamentally different approach to the meaning of
insight compared with its meaning in the clinical disciplines. The crucial difference
lies in the external focus of insight in the Gestalt and cognitive frameworks as
opposed to the internal focus of insight in the clinical disciplines. In other words,
in the case of the former, insight is directed at the solution of an external problem
(i.e. insight is equivalent to awareness of understanding a particular set task outside
of the individual). On the other hand, insight in the clinical conceptions is directed
at the understanding of something happening within the subject (i.e. insight is
equivalent to awareness and understanding of changes, such as illness or symp-
toms or disability, etc. happening within an individual). Later, this will be concep-
tualised and understood in terms of different ‘objects’ of insight assessment
(Chapter 7) but at this stage it is important to emphasise this as an important

difference in meaning.
One of the main interesting and continual areas of dispute around insight, linked
with different views on underlying mental processes, concerns the question of
whether insight represents a special mental process or whether it can be understood
in terms of ordinary mental processes. This is not a new debate and since the time
of Köhler’s experiments varying views have been expressed concerning his inter-
pretation of the animals’ behaviours (Koffka, 1925/1980). Behavioural and experi-
mental approaches to studying learning and behaviour in animals were developing in
parallel to the Gestalt approaches and explanations were framed in terms of trial-
and-error learning, and conditioning responses, etc. In a series of experiments with
human subjects designed to explore the nature and possible mechanisms under-
lying insight, Bulbrook (1932, p. 453) concluded that there was ‘no characteristic
process, operation, form of conditioning or mode of discovery, which we could
with propriety distinguish as “insight’’’. In the same year, Hartmann (1932) argued
that it was the introspective component of insight that determined its special
nature. Ogden (1932), however, disagreed and proposed that insight simply referred
to intelligent as opposed to non-intelligent behaviour. Subsequently, others tried to
unify the notion of insight within models of learning as a whole thus conceiving all
theories of learning as based on ‘ordinary’ mental processes. Kellogg (1938), com-
paring insight with trial-and-error learning viewed insight as different in degree
(‘high’ learning as opposed to ‘low’ learning) but not in kind. Similarly, Osgood
(1964) considered the differences between insight and learning by other means as
mainly terminological and hence, for him, no special processes were involved.
With the increasing focus on exploring cognitive processes underlying learning
and problem-solving, there has been a general shift in emphasis from the Gestalt
perception-like formulations to more strictly cognitive information-processing
models. This has had an effect on the conceptualisation of insight both in terms of
its nature and its likely underlying mechanisms. For example, Ohlsson (1984a, b)
attempts to integrate aspects of Gestalt theory within information-processing
models and redefines problem-solving in terms of selective searching, combining both
behavioural (trial-and-error learning) and Gestalt (productive/good thinking) con-
cepts in a specific cognitive system. As far as the nature of insight is concerned, there
seems to be a clear polarity between views of insight as ‘special’, as involving quali-
tatively different psychological processes (e.g. Metcalfe, 1986a, b, 1998; Metcalfe &
Wiebe, 1987; Schooler et al., 1993; Dominowski & Dallob, 1995; Mayer, 1995) and
views of insight as understandable in terms of ‘ordinary’ mental processes (e.g.
Perkins, 1981; 1995; Keane, 1989; Kaplan & Simon, 1990; Weisberg, 1992; 1995;
Gick & Lockhart, 1995). A few position themselves in between these poles, for
example, arguing that insight is special but not mystical (Davidson & Sternberg,
1986) or that insight is mostly non-special but a few ‘special’ processes are involved
(Seifert et al., 1995). A major proponent of the ‘special’ view of insight, Metcalfe and
her colleagues described a number of experiments which, they argued, provided
empirical support for this view (Metcalfe, 1986a, b; Metcalfe & Wiebe, 1987). The
principles behind this empirical work lay in focusing on subjects’ ‘metacognitions’
(judgements based on self-monitoring of mental states) as predictions of success in
solving so-called insight problems and non-insight problems (memory tasks, alge-
bra sums, etc.). The metacognitions were elicited either as a ‘feeling of knowing’
and/or as a closeness to solution which Metcalfe calls ‘feeling of warmth’, which the
subjects had to rate in conjunction with carrying out the various tasks. In summary,
findings across the different studies indicated that, on the basis of these metacogni-
tions, subjects were able to predict success only in non-insight problems but not in
the insight problems. In other words, there seemed to be no correlation between the
subject’s experience of feeling close to a solution and actual solution in the insight-
dependent tasks whereas in the memory tasks, for example, there was an incremen-
tal growth of feelings of warmth corresponding to subjects’ approaching of the
solutions. In addition, the solution to ‘insight problems’ was marked phenomeno-
logically by a ‘sudden flash of illumination’. This, the authors argued, indicated that
insight involved a qualitative change in mental processing. There was no incremen-
tal process of getting closer to a solution but instead the solution occurred suddenly
and unexpectedly implying a discontinuity in mental processing.
Proponents of the view that insight is not a special process have criticised such
empirical work both on methodological and on tautological grounds. Weisberg
(1992; 1995), for example, argues that the distinction between so-called insight prob-
lems and non-insight problems is false and suggests that it would be more useful to
think of problems in a multidimensional way and conceive a continuum of solutions
some of which depend on incremental steps and others on short and fast steps, etc.
His view in relation to problem-solving was that rather than invoking a special notion
of insight, ‘problem-solving should be considered as a cyclical process, involving
retrieval of information from memory and the attempt to apply this information
to the problem. Failure provides new information, which initiates further memory
search, and so on’ (Weisberg, 1992, p. 427). In other words, solutions to problems are
to be found within memory systems of subjects and depend on appropriate access
and use made of these by the subject rather than on other special mental processes.
In addition, Weisberg criticised the circularity involved in using ‘patterns of warmth’
both as a criterion of an insight problem (a problem is an insight problem because of
the pattern of warmth) and as a support for the validity of the construct (pattern of
warmth, indicating insight, elicited in relation to insight problem). Finally, the ‘Aha’
experience as a criterion of insight has also been disputed, in that subjects can experi-
ence the same phenomenon when solving ‘non-insight’ problems (Weisberg, 1995).
In subsequent work, Metcalfe (1998) developed the argument further. Responding

to the opposing view that problem solving depended on memory explanations, she
pointed out that amnesic patients accomplished problem-solving tasks (insight-
like problems involving puzzle sentences to complete) almost as well as healthy indi-
viduals even after a week’s delay (see McAndrews et al., 1987). This, she claimed,
contradicts the hypothesis that insight relies only on recollection. She further sug-
gested that there was a common insight-like metacognitive dynamic involved in
the unprimed word/picture fragment completion tasks in that subjects likewise
show no correlation between feelings of closeness to solution and actual solutions.
Thus, she proposed, ‘insight-like tasks and implicit memory tasks are one and the
same’ (Metcalfe, 1998, p. 192). It is of interest how this becomes interpreted in rela-
tion to the empirical work on insight in patients with amnesic syndromes or
dementias (see below and Chapters 4 and 5).
2.1.2 Determination of insight

In line with the specific concept of insight detailed above, its elicitation has gener-
ally depended on experiments in which subjects are given particular problems to
solve. (Some researchers have also carried out ‘naturalistic’ studies in which scien-
tists are observed working and arriving at problem solutions within laboratory
situations (e.g. Dunbar, 1995)). This is in contrast to the elicitation of insight in
general psychiatry which is dependent instead on subjective accounts of current
mental states and conditions. Interestingly, however, assessment of insight in neuro-
logical states, particularly in amnesia in focal and generalised organic brain syn-
dromes (Chapters 4 and 5), likewise has relied on patients carrying out specific
tests. Some of these have clearly been influenced by the cognitive and information-
processing approaches mentioned above. There is, nevertheless, a crucial difference
between the approaches which relates to the issue mentioned earlier concerning the
differences in focus of insight (i.e. external versus internal). Within the Gestalt and
cognitive psychologies, insight is determined as present when a particular task is
successfully solved with or without the sense of enlightenment demanded by some
of the definitions. Judgements made by subjects concerning their likelihood of
success in such tasks (i.e. metacognitions) are deemed as irrelevant to insight in
the sense that subjects’ predictions have no correlation with successful solutions
(Metcalfe, 1998). In contrast to this, within neuropsychological approaches to
assessment of insight in patients with amnesia or dementia, insight is determined
not on the basis of the solution to particular problems (in this case memory tasks,
therefore ‘non-insight’ problems) but on the discrepancies between patients’ judge-
ments of performance (prediction or postdiction) and actual performance. In other
words, here it is the metacognitions that are at the core of the assessment since these
represent subjects’ own judgements of their mental states, the latter being the foci
(or ‘objects’) of insight assessment. Thus, for example, the ‘feeling-of-knowing’

metacognition has been used as an indirect assessment of awareness or insight in
such patients (Shimamura & Squire, 1986; Shimamura, 1994, see Chapter 4). What
this shows, and will be highlighted in more detail later (Chapter 7), is that similar
terminology (metacognition and insight) used in the different contexts (clinical
and non-clinical) can have different and even contradictory meanings and applica-
tions. Later, it will be demonstrated that the ‘object’ of insight assessment (solution
to a problem, mental/physical symptoms, illness, etc.) is crucially important in
determining the phenomenon of insight elicited.
As evident from the question concerning whether insight be considered as a spe-
cial or non-special process, the nature of the particular problems given to subjects
to solve for the purpose of eliciting insight has also been a source of some dis-
agreement. In his experiments, Köhler explicitly devised problems for the chim-
panzees that could not be solved directly but involved roundabout (‘Umwege’) or
indirect methods of solution. Duncker, likewise, devised problems that, following
Gestalt principles, depended on utilising given components in novel ways so that
the subject would have to ‘restructure’ the situation in order to get to a solution.
Subsequent ‘insight problems’ have been modelled along the same lines, i.e. as
problems which are non-routine (Mayer, 1995), demanding some sort of restruc-
turing, a new way of looking at the components and their relationships. This dis-
tinction between insight and non-insight problems is held by many (Sternberg &
Davidson, 1995). One difficulty, however, as pointed out by Weisberg (1995), is
that there is no system of classifying problems into those in which insight occurs
and those in which it does not. He argues that many of the classical ‘insight prob-
lems’ are not, in fact, solved through insight and hence should not be considered as
‘insight problems’. Others have qualified views. For example, Smith (1995) defines
insight problems as problems whose solution is more likely to be reached by
an insight experience, thus, allowing for other possible means of solution though
not specifying any criteria for this. Schooler et al. (1995) distinguish between
insight problems, non-insight problems and hybrid problems, the latter involving
solutions through a mixture of both insight and non-insight means. Once again
though the criteria for determining such distinctions are difficult to set and tend to
depend on the manner in which problems appear to be solved, thus giving rise to
some circularity.
2.1.3 Stages and mechanisms underlying insight

As mentioned earlier, views on the stages and possible mechanisms underlying
insight have also been influenced by the shift from the original Gestalt conceptions to
the more cognitively orientated information-processing models of mental processes.
The conceptualisation of insight in terms of its nature and likely underlying
processes has reflected this shift particularly in the move away from perceptual
models (e.g. Köhler, 1924/1957; Hutchinson, 1941) to more ‘cognitive’ models of
understanding insight (Sternberg & Davidson, 1995). Nevertheless, the perceptual
metaphor is still evident in many of the processes proposed to underlie insight and
this, amongst other things, helps to subdivide views in this area. Some explanatory
mechanisms underlying insight are thus framed in perceptual terms, such as ‘new
perceptual organisation’ (Ellen & Pate, 1986) or ‘locus of explanation in the per-
ceptual world’ (Ippolito & Tweney, 1995).
In general though, insight is conceived as developing following some sort of
restructuring of the problem. The nature of this ‘restructuring’ process, however,
has been a source of difficulty in terms of agreement concerning what precisely
this process involves. Duncker (1945) referred to an analysis of the problem situ-
ation and removal of blocks which impeded such analysis. Similarly, the Russian
Psychologist Rubinštejn (1960) emphasised the importance of reformulation of the
problem and the interactional relationship between reformulation and analysis.
Clearly, some researchers view the restructuring process as perceptual, e.g. a percep-
tual reorganisation (Ellen & Pate, 1986) or pattern recognition (Schooler et al.,
1995). In more information-processing terms, the restructuring has been described
as a change in the representation of the problem, i.e. finding the right problem
representation (Ohlsson, 1984a, b; Kaplan & Simon, 1990; Gick & Lockhart, 1995).
Other suggestions involving methods of restructuring have included: use of ana-
logue, i.e. solving a problem on the basis of its similarity to a different problem
(Gick & Holyoak, 1980; 1983), completing a schema, i.e. the addition of missing
pieces to an incomplete though appropriate mental representation (Mayer, 1995;
Seifert et al., 1995), as a search of memory and working with the information
accrued (Weisberg & Alba, 1982; Weisberg, 1992; 1995), apprehension of relations
and fluency of thought (Ansburg, 2000), and many more (Sternberg & Davidson,
1995). Davidson and Sternberg (1986) suggest three distinct processes consisting of:
(i) selective encoding (i.e. relevant information is sifted out from the irrelevant),
(ii) selective combination (i.e. the assembling of seemingly unrelated facts or ideas
into a coherent whole) and (iii) selective comparison (i.e. relating newly acquired
or proposed concepts to the older concepts, analogies).
One of the more consistent findings in the descriptions of processes underlying
insight has related to the postulated stages involved. Such stages had already been
described in the early Gestalt work (Wallas, 1926 (cited in Mayer, 1995); Hutchinson,
1941) and have persisted, with modifications, within the cognitive literature
(Sternberg & Davidson, 1995). In brief, the stages are described as follows:
1 A mental preparation: where the problem or situation is first confronted and

where unsuccessful attempts at solving take place.
2 Incubation: where the problem is put aside temporarily. Various mechanisms

have been proposed to underlie this stage such as unconscious processing
(Csikszentmihalyi & Sawyer, 1995; Seifert et al., 1995), or contextual change, i.e.
being away from the problem situation can help remove the block to solution
(Smith, 1995). Perkins (1995), on the other hand, rejects the need for an incu-
bation stage and unconscious mental processing. Instead, he focuses on the
problem space metaphor (i.e. the notion of thought moving through physical
space) suggesting that the subject is simply engaged in a continual search
through ‘possibility’ spaces.
3 Illumination: when suddenly and unexpectedly the solution is found, not pre-
ceded by the ‘feeling-of-knowing’ characteristic of non-insight problem-solving
(Metcalfe, 1998). This is accompanied by the subjective feeling of satisfaction
(‘Aha’ experience) and some even specify an increase in physiological arousal
(Seifert et al., 1995).
4 Verification: where details of the problem solution are worked out and tested.
It is evident that there is a wide range of descriptions and analyses of possible

processes underlying insight. Indeed, and in contrast to studies of insight in clin-
ical areas, much more emphasis has been placed on empirical investigation of such
processes than on relating insight to other variables or attributes. In terms of the
latter, there is little research in this field. Davidson (1995), on the basis of empir-
ical work exploring insight in subjects with high IQ and those with lower IQ reported
that insight solving was associated with greater intelligence. Perkins (1995), on the
other hand, states categorically that insight has little to do with intelligence or cog-
nition. In the area of creative insight, some studies have explored the relationship
between affect and creative problem-solving, and suggest that positive affect, as
opposed to neutral or negative affect, enhances insightful problem-solving (see
Friedman & Förster, 2000, for review and experimental evidence). Finally, some
suggestions have also been put forward linking insight problem-solving with cog-
nitive processes associated with right hemispheric function (Fiore & Schooler,
1998) and, in this context, Pierce (1999) has proposed a possible evolutionary basis
to the phenomenon of insight.
2.1.4 Summary
In summary, the concept of insight in Gestalt psychology is viewed in a very spe-
cific sense. Bound up in the theory of perception that is central to Gestalt thinking,
insight results from the reorganisation or restructuring of a particular situation or
problem, based on some form of perceptual shift (‘things falling into place’). With
the development of cognitive approaches, the perceptual analogy has largely been
superseded by information-processing-like models though the behavioural aspect
of the Gestalt notion remains. Insight has been studied both as an ‘intelligent
behaviour’ through the solving of specific tasks and as a ‘creative process’ through
retrospective and prospective research into scientific methods (Dunbar, 1995).
In contrast to the broader and more general meanings of insight in relation to
mental illness (see next chapter), the specificity of the concept of insight in Gestalt
and cognitive psychology is striking and manifest in several ways. Firstly, the experi-
ence of insight (whether conceived as a state or process) is characterised by certain
features, namely, suddenness, spontaneity, unexpectedness and satisfaction (Seifert
et al., 1995). In other words, there is the sense of ‘enlightenment’ or ‘revelation’ that
can be observed both in behavioural (the sudden smooth solving of a task) and in
subjective (the ‘Aha’ experience) terms. Secondly, insight so conceived is a discrete
event with determinable boundaries. Thirdly, insight is directed specifically at the
solution of a particular task which, in contrast to the clinical perspective, lies exter-
nal to the individual.
Partly as a result of changes in theoretical approaches and partly because of
some circularity involved in studying the phenomenon of insight in so-called
insight problems, opposing views have emerged concerning the validity of both the
insight construct as such and the problems used to determine insight.
2.2 Insight in psychoanalytic psychology
In contrast to general psychiatry, the concept of insight within psychoanalytic

psychology has, from the very beginning, held a central position as an integral com-
ponent of psychoanalysis and, to a variable extent, of psychoanalytic psychotherapies.
In other words, at the very core of psychoanalytic theory, as developed by Freud,
was the search for a deep self-knowledge which was both inherent to the method
of psychoanalysis itself and essential to any consequent personality or therapeutic
change that ensued (Strachey, 1934; Fenichel, 1945; Freud, 1973a, b). Insight or
self-knowledge as conceived in this psychoanalytic sense shares some similarities
with insight as understood by Gestalt and cognitive psychology, and with insight as
recognised in general psychiatry but it also shows important differences. An obvi-
ous and fundamental difference lies in the ‘depth’ of self-knowledge contained
within the concept. In psychoanalytic terms, the depth refers to a level of under-
standing that an individual can develop in relation to his/her mental processes
(and consequent behaviours) and these, in turn, are directly connected to the tri-
partite models of the mind as elaborated by Freud. Accordingly, in relation to the
earlier topographical model of the mind, self-knowledge can thus relate to con-
scious, preconscious and/or unconscious mental processes. Within this metaphor,
the deepest level of knowledge refers to knowledge of unconscious mental
processes. As Freud clearly stated, ‘our therapy works by transforming what is
unconscious into what is conscious’ (Freud, 1973a, p. 321). Later, as Freud’s views
changed and he developed the structural model of the mind, self-knowledge was
conceived in a similarly deep but more active and integrative way (‘where id was
there ego shall be’ (Freud, 1973b, p. 112)). Likewise, emphasising the depth of self-
knowledge required for therapeutic benefit, Segal points out that insight ‘… must
be deep enough. It must reach to the deep layers of the unconscious and illuminate
those early processes in which the pattern of internal and external relationships is
laid down, and in which the ego is structured’ (Segal, 1962, p. 212).
Interestingly, whilst the concept of insight as a form of deep self-knowledge can
be discerned in the earliest psychoanalytic writings, the term ‘insight’ only began to
be used in this context around the early 1950s. Freud used the term ‘insight’
(‘Einsicht’ or ‘Einblick’) predominantly in the generic sense to denote knowledge or
awareness of being ill. According to Anna Freud (1981), there was only one instance
where Freud used the term ‘insight’ in the deeper sense of revelation as in the much
quoted line from the 1931 preface to the 3rd English edition of The Interpretation
of Dreams: ‘insight such as this comes to one’s lot but once in a lifetime’ (Freud, 1900,
p. xxxii). Nevertheless, the concept of insight in the sense of a self-understanding
that reaches the unconscious levels of the mind has been implied in both the psycho-
analytic aim and in the psychoanalytic treatment (‘that here understanding and
cure almost coincide, that a traversable road leads from one to the other’ (Freud,
1973b, p. 180)). This conceptualisation of insight was subsequently made explicit
by the convergent use of the term ‘insight’ in later psychoanalytic writings (e.g.
Martin, 1952; Zilboorg, 1952; Kris, 1956) and, since then, has continued to be the
source of much debate. In this regard, two main areas will be explored in this sec-
tion. Firstly, the concept of insight itself will be reviewed and, secondly, the role of
insight in psychoanalysis and psychoanalytic therapies will be examined in terms
of its perceived contribution to promoting change or ‘cure’. Whilst a division between
these areas is being made here for the purpose of analysis, it has to be understood
that this is something of an artificial division and the two areas considerably overlap.
Indeed there is, as will be seen, a degree of circularity involved when exploring the
relationship between insight and change in a situation where the conceptualisation
of insight itself incorporates the notion of psychic or personality change within its
definition.
2.2.1 The concept of insight

As with exploration of insight in other disciplines, conceptualisation of insight within
the psychoanalytic field likewise shows variability in views held. Differences emerge,
for example, in definitions and characteristics of insight, its essential components
and classification, its likely mechanisms of development and the possible processes
involved, etc. Nonetheless, the consistent core to the psychoanalytic concept of
insight, referring to the knowledge or understanding of one’s unconscious (or only

partly conscious) mental processes, has persisted. The latter, in the psychoanalytic
framework, encompass the instinctual drives, resistances and defence mechanisms
such as repression, identification, introjection, denial, etc. thought to underlie per-
sonality structure and mental disorders, particularly neurotic manifestations
(Fenichel, 1945). With the increasing use of the term ‘insight’ in this context, it was
quickly recognised that the concept needed clarification (Zilboorg, 1952; Roback,
1974). Questions were thus asked about the meaning and nature of insight in
terms of the content of knowledge involved, the way in which the knowledge was
attained and the consequences of such knowledge. In turn, such questions raised
various viewpoints and perspectives, and Freud’s early implicit conceptualisation
of insight simply as an awareness of unconscious mental processes was both elab-
orated and challenged. Loewenstein (1956) formulated this explicitly when he
pointed out that insight was a more comprehensive concept than ‘bringing to con-
sciousness’ (in the Freudian sense) but comprised also of ‘the re-establishment of
connexion’. This was echoed by Shengold (1981) and Blum (1979) who stated
‘insight does more than make conscious; it establishes causes, meanings and con-
nections’ (p. 51). Content of the knowledge thus constituting insight became con-
ceived in more involved and complex terms, and resulted in offers of a range of
definitions of insight capturing or emphasising different aspects of such know-
ledge. For example, some definitions are wide and general as in Myerson (1960)
who stresses the newness of knowledge relating to oneself and to one’s interaction
with the world, or Glucksman (1993) who suggests that insight refers to ‘know-
ledge or some type of rationale that helps the patient explain his/her symptoms or
problems’ (p. 163). Other definitions are more technical and specific. For example,
Neubauer (1979) defines insight during psychoanalysis as ‘the expansion of the ego
by self-observation, memory recovery, cognitive participation and reconstruction
in the context of affective reliving’ (p. 29). In contrast, Joyce and Stoker (2000) refer
to an individual’s ‘self-knowledge (which) gradually leads to modification of his
internal representations’ (p. 1139), and many other examples can be found.
A number of attempts have been made to organise the complex conceptualisa-
tion of insight underlying such definitions and, here again, a range of distinctions
have been suggested to differentiate between various types of insight. One of the
earliest distinctions proposed has been that between intellectual and emotional
insight. In broad terms, this refers to the difference between knowledge that is
understood and accepted at an intellectual or theoretical level and knowledge that
is grasped at a deeper level in the sense that the individual feels or experiences it in
a direct way. However, this is a fairly general distinction for it is apparent in the
psychoanalytic literature that it is interpreted in many different ways giving rise to
some confusion (Zilboorg, 1952). Hatcher (1973) argues that this distinction was
already present in Freud when the latter differentiated between ‘knowing but
not knowing’ – as the intellectual understanding of the repressed (i.e. distant, non-
involvement of the self with the unconscious) – and emotional understanding
which was attained through the direct (experiential) struggle with the repressed in
the transference reaction. In a similar vein, without referring to insight specifically,
Strachey (1934) distinguishes between descriptive interpretations which can lead
to intellectual understanding and ‘mutative’ interpretations which lead to modifi-
cation of the patient’s superego (i.e. to sustained change). The mutative interpret-
ation, he specifies, ‘must be emotionally immediate; the patient must experience it
as something actual’ (Strachey, 1934, p. 150). In general terms, it is this emotional
or experiential aspect of insight that is considered one of the crucial aspects of psy-
choanalytic insight, one that is frequently equated with the definition of psycho-
analytic insight itself, helping to differentiate it from insight as used in other areas
(lay usage, general psychiatric usage, etc.) and often considered as the main factor
in promoting change (Segal, 1962; 1991).
Other more specific approaches have been taken to distinguish between different
types of insight. For example, Reid and Finesinger (1952) differentiated between neu-
tral, emotional and dynamic insight. Objecting to the term ‘intellectual’ insight on the
grounds of claiming that all insight was by definition intellectual (or cognitive), they
proposed distinctions based on the level at which patients could understand the rela-
tionship between antecedents and manifested symptoms or behaviours. They defined
neutral insight as occurring when patients were able to understand and accept super-
ficial links between antecedents (e.g. quarrelling with spouse) and symptoms (e.g.
indigestion). They further specified that at this level, emotions were not involved
either in the act of understanding or as a release resulting from the understanding.
Emotional insight, on the other hand, occurred when patients’ understanding of the
association between antecedents and symptoms included either an emotional com-
ponent in the understanding process itself (e.g. anxiety/hostility underlying the quar-
relling with spouse) or if emotion was experienced as a result of that understanding.
Finally, dynamic insight was defined as the deepest form of insight when patients were
able to understand the relationships between antecedents and symptoms in the
Freudian sense of ‘penetrating the repressive barrier and making the ego aware of
certain hypercathected wishes that were previously unconscious’ (Reid & Finesinger,
1952, p. 731). In other words, here the connection between antecedents and symp-
toms was based on knowledge of unconscious motivations and defences thought to
underlie the emotional component of the antecedent. Of these three kinds of insight,
dynamic insight was conceived as producing the most extensive changes in the per-
sonality of the subject and the most lasting therapeutic benefits.
Whilst agreeing that insight had to involve the patients’ understanding of their
unconscious mental processes in order to achieve therapeutic benefit, Richfield
(1954), argued that recognition of such unconscious processes on the part of the
patient did not necessarily lead to a change in ‘neurotic’ behaviour. He proposed
that it was not the content of the knowledge that was essential to the therapeutic
effect of insight but the form in which this knowledge was experienced. Thus, on
the basis of Bertrand Russell’s classification of knowledge, Richfield distinguished
between insight gained by description and insight gained by acquaintance. When
patients attained descriptive insight, they became aware of the ‘truths’ about them-
selves by acknowledging the words of the analyst. When, however, they attained
ostensive insight, they became ‘personally acquainted’ with the ‘truths’, for example,
through transference when particular emotions and their significance were
brought directly to patients’ awareness. In other words, it is the method of gaining
knowledge by direct experience that is considered the crucial component of insight
irrespective of the content of such knowledge.
Bibring (1954), in contrast, focuses on the content of knowledge as a distin-
guishing factor between two forms of insight. Specifying also that different tech-
niques are needed to achieve these insights he differentiates between insight
through clarification and insight through interpretation. The former is based on
working with conscious and/or preconscious processes of which the patient is not
sufficiently aware and the latter is based on working exclusively with unconscious
mental processes. Consequently, he argues, the two forms of insight are ‘dynam-
ically’ different. Insight through clarification, because it deals only with conscious
material, does not encounter resistance and patients are able to develop a more
‘objective, realistic perspective’ on problems and thereby achieve greater control
over them. In that sense, the ego becomes ‘detached’. Problems are not resolved but
are viewed from a different perspective. Insight through interpretation, on the
other hand, results in direct involvement of the ego in the process of dealing with
the unconscious material but results in better solutions to underlying pathogenic
conflicts. Somewhat differently, Myerson (1965) differentiates between psychoana-
lytic insight and reality-oriented insight on the basis of what seems to be a deeper
form of understanding in the former. Here again, the focus is on knowledge of
unconscious mental forces and, in particular, of these being directly experienced in
the mental state. In reality-oriented insight a more superficial knowledge is defined
with focus on realistic appraisals of relationships and environment rather than on
underlying instinctual conflicts.
Describing some of the attempts at classifying the various modes of insight as
ad hoc and intuitive rather than systematic or analytical, Lindén (1984; 1985) sets out
a comprehensive but complicated framework for classifying insight using a develop-
mental approach. She stresses the need for an adequate theory of cognition and for
this purpose uses Nilsson’s genetic-hierarchical theory which itself is based on an inte-
gration of Piaget’s developmental theories and Freud’s topographical representation
of the mind. Insight, she proposes, can be hierarchically (i.e. structurally) localised
in relation to sensorimotor, perceptual or conceptual levels of cognitive activity
and along conscious–unconscious and intellectual–emotional dimensions. In
recognition of the confusion arising from the general use of the term ‘insight’ she
argues for the need to specify (within her proposed framework) the particular
insight manifested within an analytic situation.
Apart from seeking to clarify and define various modes of insight, psychoanalytic
approaches have also explored the possible processes and components involved. In
contrast to the Gestalt notion, there is a much greater emphasis on conceptualisation
of insight as a long gradual process in which insight is gained in slow increments
(Strachey, 1934; Kris, 1956; Hatcher, 1973; Abrams, 1981; Mangham, 1981; Poland,
1988; Segal, 1991). Zilboorg (1952) argues that it has to be an affective process, in
that insight can only develop through successive affective reconstructive experiences
(thus arguing for the emotional/experiential component of insight as the crucial
constitutive factor). Conceived as an ongoing process, there is the additional impli-
cation that insight can never be complete, that it is indefinite, and applies to the
whole life of an individual and, indeed, some have stated this explicitly (Blum, 1979;
1992; Poland, 1988; Segal, 1991). Only a few authors refer to insight as an ‘immedi-
ate’ or sudden illumination as used in the Gestalt sense (Rhee, 1990; Elliott et al.,
1994) though some writers allow for the possibility of sudden flashes of insight
occurring within the ongoing process as a whole (Martin, 1952; Blum, 1979; Olmos-
de Paz, 1990; Wilson, 1998; Joyce & Stoker, 2000). Most views seem to agree that the
process of insight is an active and creative one (Blum, 1979; Freud, 1981; Pollock,
1981; Shengold, 1981; Sternbach, 1989). Thus, it is active in the sense that the indi-
vidual has to be him/herself directly involved in the process. Freud recognised this in
his later work when dealing with the phenomenon of resistance. For this reason also,
some writers have argued specifically against the notion of the analyst ‘giving’ insight
to the subject (Zilboorg, 1952; Poland, 1988). The process is seen as a creative one in
that attaining insight or understanding of unconscious mental processes is viewed as
involving a restructuring or reintegration of aspects of the subject’s ego to form
something new rather than a restoration or clarification of the old (Segal, 1962; 1991;
Freud, 1981; Sternbach, 1989). Abrams (1981, p. 261) puts this very clearly:
Insight-producing activity entails taking things apart and putting them together differently. It is
the highly specialized expression of fundamental differentiating and integrating capacities, the
operation of a relatively intact higher level of mental organisation. The new assemblage of drive
and defence, desexualized and/or restructured, is an entirely different product from what has
preceded it.
Interestingly, this conception of restructuring shares strong similarities with the

Gestalt notion of insight. This is often reflected in the terminology used, e.g. ‘each
part of a meaningful whole’ (Hatcher, 1973, p. 395) or, more explicitly in Myerson
(1965, p. 791) when referring to stages of insight development which, ‘become inte-
grated into a Gestalt through the psychoanalytic process’. Similarly, in Neubauer
(1979, p. 34),‘[a] new Gestalt is established, a reorganised ego structure’. At the same
time, however, the concept of restructuring in the psychoanalytic sense refers in a
much more direct sense to the deeper connotation of psychic or personality change.
Mechanisms and possible components underlying psychoanalytic insight tend to
be difficult to disentangle, reflecting the conception of insight as an ongoing restruc-
turing process. In the main, the experience and interpretation of the transference
situation has generally been considered as the most effective source of gaining insight
(Strachey, 1934; Zilboorg, 1952; Segal, 1962; 1991; Sternbach, 1989). In other words,
whilst interpretations of other aspects of the patient’s mental life are viewed as import-
ant in the development or creation of insight within the individual, it is the inter-
pretations relating to the transference relationship itself that are seen as the most
significant in promoting change. This view probably relates to the conception of
insight in the deeper sense of something that is experienced directly or emotionally.
Thus, in the analysis of the transference relationship, the individual is confronted with
emotions/thoughts which, on resonating with earlier experienced feelings, gain a
direct or immediate quality thereby achieving a deeper personal understanding.
Some authors have emphasised self-observation on the part of the subject as an
important prerequisite or component of the process of insight (e.g. Hatcher, 1973;
Kennedy, 1979; Neubauer, 1979; Abrams, 1981). A few authors have tried to break
up the process of attaining insight into separate components or stages. For example,
on the basis of an analysis of two case reports, Abrams (1981) proposed several
empirical components to ‘insight-producing activity’ that were common to both
cases. These included the following: (1) attention, initially diffuse but becoming
more focused, (2) distinct emotional tone, appropriate to the ideas, (3) recognition
of link between different components (e.g. dreams or memories), (4) free move-
ments within time periods, due to awareness of the meaningful relationship
between past and present, (5) a sense of inner unity within the patient and, (6) at
moment of discovery, a recognition that something new has happened. On the
other hand, Elliot et al. (1994) based their model on a study comparing ‘insight-
events’ in patients undergoing either psychodynamic interpersonal psychotherapy
or cognitive-behavioural therapy. They proposed a five-stage model of insight
comprising of: (1) contextual priming, (2) novel information, (3) initial distanti-
ated processing, (4) ‘insight’ and (5) elaboration. This latter model shares many
similarities with the Gestalt and cognitive models described earlier. This is perhaps
influenced by the fact that these researchers were using a much narrower definition
of insight as a discrete event thus running counter to the general conception of
insight in the psychoanalytic sense. The difficulties in empirically defining and
assessing insight in such situations, however, is made apparent in this study and
raises questions concerning the validity of extending the model and the methods
used to other areas, particularly, as clearly the content of ‘insight-events’ (as deter-
mined by qualitative analysis) in the two patient groups was very different.
Others have suggested that the ability to empathise was crucial to the development
of insight, viewing the interactive process between subject and analyst as the mech-
anism underlying insight acquisition (Dymond, 1948). In fact, the contribution of
the analyst, in terms of relationship to, and interaction with, the analysand, towards
the attainment of insight, has been the subject of much discussion and of a variety of
disparate views. Part of the problem, however, in trying to clarify some of the differ-
ent perspectives is that there is confusing overlap with different aspects of the rela-
tionship between analyst and insight. These aspects can be broadly divided into three
areas: (i) the meaning of analyst insight, (ii) the role of the analyst in the insight
process and (iii) the role of the analyst in therapeutic change. This last area will be
dealt with in the next section (see below). Concerning the analyst’s insight, whilst
there is general agreement that this has to be differentiated from the patient/subject
insight, it is also apparent that there are opposing views as regards its meaning. Thus,
some authors regard it as the understanding (intellectual and/or emotional) the ana-
lyst has of the patient’s mental life and processes (Richfield, 1954; Blum, 1979; 1992;
Pollock, 1981; Levenson, 1998). Indeed, Pollock (1981), focusing specifically on the
nature of analyst’s insight in relation to understanding elderly patients with cognitive
impairment, proposes a distinction between inductive insight and deductive insight
based on the type of knowledge held by the analyst. Thus, he defines the former as
referring to the understanding of antecedent–consequent linkages as gained from
transference repetition and the latter as referring to the understanding of meaning in
relation to personal phenomena as gained from reconstruction. On the other hand,
others argue that the analyst’s insight cannot refer to the analyst’s understanding of
the patient’s mental life but must refer to self-understanding, i.e. the analyst’s under-
standing of own mental processes (Shengold, 1981; Poland, 1988; Joyce & Stoker,
2000). In other words, there is a polarity between those who do and those who do not
hold that knowledge of the self is crucially different from knowledge of others. Thus,
Anna Freud (1981) differentiated between knowledge of one’s inner world (termed
‘insight’) and knowledge of one’s external world (termed ‘understanding’). Similarly,
Shengold (1981) suggested that the analyst’s insight into the patient’s mind is called
‘outlook’ and should be distinguished from the analyst’s insight into his/her own
mind (‘insight’). Lindén’s (1984; 1985) distinction between insight and outsight is
based on a similar principle.
The role of the analyst in the insight process has likewise been the subject of mixed
views. Here the views range from those who focus on the insight process as some-
thing that is happening predominantly within and by the patient, albeit with
guidance provided by the analyst (e.g. Bibring, 1954; Segal, 1962; 1991; Blum, 1979;
1992) to those who see the insight process as intrinsically interactive between the
patient and analyst (Loewald, 1960; Shengold, 1981; Poland, 1988; Pulver, 1992;
Etchegoyen, 1993; Levine, 1994; Steiner, 1994; Currin, 2000). Loewald (1960) argues
against the traditional conception of the analyst as neutral and objective, a ‘reflecting
mirror’ whose role is to observe and reflect back to the patient the latter’s conscious
and unconscious processes through verbal communication. Instead, he contends, in
order for the patient to gain insight and attain structural personality changes, signifi-
cant interactions between the patient and analyst must take place in which the ana-
lyst has a specific and active role. The analyst, he maintains, has to function as a
‘co-actor on the analytic stage’ and in order to do that, must be actively empathic and
be able to regress within himself to the level of organisation of the patient. Insight
attainment is thus viewed as an actively interactive process between the patient and
analyst. Some differences emerge, however, between views concerning the nature or
levels of interaction underlying the insight process. For example, Poland (1988)
stresses the deep collaborative aspect of the patient–analyst interaction and the emo-
tional engagement of the analyst in this process, ‘the struggle towards insight is a
shared task, actualised in the transference–countertransference process’ (p. 355). At
the same time, he is clear that within this interaction, the analyst remains ‘an out-
sider’, his mind interacting, but not merging, with that of the patient and, hence, not
becoming part of the patient’s mind. On the other hand, others suggest a more inte-
grative model where there is direct incorporation of the analyst within the patient’s
mind by means of introjection (Strachey, 1934; Olmos-de-Paz, 1990). Some authors
stress the interdependency of insight as self-knowledge and the empathic interactive
relationship with the analyst, pointing out that one could not happen without the
other (Pulver, 1992; Etchegoyen, 1993; Carveth, 1998; Currin, 2000). Others have
focused more on the analyst in the interactive process. For example, Levine (1994)
and Steiner (1994) both emphasise the lack of ‘objectivity’ within the analyst, argu-
ing that the analyst’s interventions were inevitably affected by personal values,
desires, as well as by unconscious influences which were reactivated during the ana-
lytic session. Thus, they stress the need for analysts to have insight into themselves in
order to be effective. Similarly, Currin (2000) emphasises the need to include the
analyst’s insight into him/herself as crucial to the integrative process of insight devel-
opment in the patient. Sternbach (1989) and Sampson (1991) pointed out that it was
possible for patients to develop insights without the necessity of the presence of the
analyst (although based on previous analytic work).
2.2.2 The role of insight in psychoanalytic therapy

Closely linked, and sometimes difficult to separate from, the conceptual debate
around insight is the other main area giving rise to mixed views, namely the role of
insight within psychoanalytic therapy. The problem is, moreover, beset by the
complexities of identifying goals of psychoanalysis and psychoanalytic psychother-
apies in general (McGlashan & Miller, 1982). Nevertheless, how important is the
attainment of insight for the therapeutic benefit of the patient? Fisher and Greenberg
(1977) suggest that Freud’s own concept of insight in relation to therapy and cure
changed. They point out that while initially Freud maintained the existence of
a direct relationship between the attainment of insight and behavioural change
or cure, he later acknowledged the equal importance of time, working through and
inner resistances. However, Freud’s work can be interpreted rather as a change in
the conceptualisation of insight from a passive (making unconscious conscious) to
an active (confronting forces of resistance) form with both being essential to per-
sonality or therapeutic change (see also Hatcher, 1973). Since Freud’s time, there
have been disparate views on the relationship between insight and change.
As already mentioned, one problem here is differentiating between personality
or psychic or structural change which, in most conceptualisations of psychoana-
lytic insight, is intrinsic to the definition of insight itself and actual therapeutic
change or improvement from symptoms. Often this is not made explicit and is dif-
ficult to infer. Some authors have alluded to this distinction when pointing out that
the development of insight does not entail therapeutic improvement (e.g. Zilboorg,
1952; Neubauer, 1979). More overtly, Lehmkuhl (1989) argues for the need to sep-
arate the concept of emotional insight from the concept of cure and that the for-
mer does not necessarily lead to the latter. Views concerning the role of insight in
contributing to the development of specific therapeutic improvement fall broadly
into three main groups. Firstly, for many, insight remains the crucial factor in
achieving symptomatic relief or cure (Strachey, 1934; Loewenstein, 1956; Segal,
1962; 1991; Blum, 1979; 1992; Schmukler, 1999). Thus, Blum (1979) states that
‘analytic “cure” is primarily effected through insight and not through empathy,
acceptance, tolerance, etc.’ (p. 47) and similarly, a few years later, he reiterates that
insight is the ‘unique critical agent of psychic change in clinical psychoanalysis’
(Blum, 1992, p. 257). His views are echoed strongly by Segal (1962; 1991) who
maintains that insight is central to therapeutic change. Interestingly, she suggests a
number of conditions (e.g. stable analytic environment, right attitude on the part
of the analyst, favourable countertransference, analyst’s correct understanding/
interpretation, correct timing and depth of interpretation) which are also import-
ant in promoting cure but only by providing the right background for the devel-
opment of insight itself. The conditions themselves clearly refer to factors relating
to the analyst. However, these are presented very much as extrinsic to the develop-
ment of insight in contrast to the intrinsic, integrative way such analyst’s factors
are considered when the insight process is conceived as more explicitly inter-
actional (see above). Others qualify the type of insight likely to promote the greatest
curative effect, e.g. dynamic insight (Reid & Finesinger, 1952), insight through
interpretation (Bibring, 1954) or ostensive insight (Richfield, 1954). On the other
hand, Valenstein (1981) suggests that rather than having a direct curative effect,
insight, through its effect on restoration of ego function, facilitates the conscious
dealing of problems at a secondary process level.
Secondly, many authors in this area express doubts concerning the central role
given to insight in the curative process and suggest that other factors may be more
important in determining therapeutic effect (Kohut, 1977; Carveth, 1998). For
example, Alexander and French (1946) emphasise the role of the ‘corrective emo-
tional experience’, i.e. the curative effect of re-experiencing earlier conflicts within
the transference relationship but in a context of the analyst assuming a different
(and hence therapeutic) attitude from the original person of the past. The analyst
in general has been given a more prominent role in helping to achieve therapeutic
benefit by various means including providing a supportive environment and
through the patient’s relationship with both the analytic/transference personality and
the ‘real’ personality of the analyst (Blum, 1992; De Jonghe et al., 1992; Glucksman,
1993). Some suggest that insight is not the cause but the consequence of thera-
peutic change. For example, Cautela (1965), reporting on three patients undergoing
desensitisation for anxiety problems, found that they showed increased insight with
improvement. He proposed the possibility that some insight-oriented therapies
might be analogous to desensitisation procedures and that as patients relived their
anxieties in the analytic situation, these represented successive re-exposures and it
was this process that resulted in insight. Frank (1993) in a similar though more
integrative vein also suggests that behavioural change (e.g. as achieved through
cognitive-behavioural techniques) could help promote insight. This in turn could
promote further behavioural change and thus it was this cycle between behaviour
and analytic processes that could lead to the positive clinical outcome.
Thirdly, and probably most prevalent, is the view that insight and non-insight
factors are equally important in promoting therapeutic change, particularly where
factors such as interaction with the analyst are viewed as intrinsic to, or interde-
pendent with, the insight process itself (De Jonghe et al., 1992; Pulver, 1992;
Etchegoyen, 1993; Carveth, 1998; Currin, 2000). De Jonghe et al. (1992) provide
a two-factor model in which both insight and ‘support’ are seen as important factors
to therapeutic change based on different schools of psychoanalytic thought. Thus,
insight, as a curative factor, is embedded within the classical Freudian background of
ego psychology and addressing the intrapsychic conflicts thought to be responsible
for pathology. On the other hand, ‘support’, as a curative factor, is contextualised
against the postclassical analytic period (Anna Freud, Klein, Winnicott, etc.) of
a psychology focusing on developmental arrest. Support in this case addresses the
trauma thought to be the original pathogenic factor. Adopting the term ‘mutative’
to refer to the structural (and clinical) change that can occur with both ‘insight’
and ‘support’, De Jonghe et al. (1992) stress that both processes are important and
occur simultaneously during analysis.
One of the problems in trying to answer the question of the relative contribu-
tion of insight and other factors to symptomatic improvement is the difficulty
faced by empirical research in this area. Whilst the need for systematic research in
this area has been well recognised (Roback, 1971; 1974; Hatcher, 1973; Wallerstein,
1983), in practical terms this does pose numerous problems and consequently
empirical research has been relatively limited. Reviewing empirical studies in this
area, Roback (1971) concludes on the basis of identified methodological limita-
tions that there is a need for future studies to: firstly, adequately define insight in
empirical studies; secondly, employ measures that can capture the degree of insight
produced; thirdly, report on the specific operations carried out by the therapists in
bringing about the development of insight and fourthly, provide validating mater-
ial showing that insight has been developed. Such issues remain valid and have
been reiterated in subsequent reviews (Crits-Christoph et al., 1993). Clearly, how-
ever, one of the major difficulties identified concerns the translation of what is
obviously a complex concept into an operational definition of insight that can cap-
ture and measure at least some of its constituents. As in other clinical areas, a num-
ber of different approaches have been taken and, correspondingly, this is likely to have
contributed to the mixed ensuing results. Some of the early studies, for example,
define insight in terms of the congruence between patient views of themselves and
views held by others, with the assumption that ‘others’ hold the ‘correct’ views
(Dymond, 1948; Feldman & Bullock, 1955; Mann & Mann, 1959). Similar methods
have been adopted in the assessment of insight in patients with organic brain dis-
orders (Chapters 4 and 5) but, in the psychodynamic field, this raises particular ques-
tions concerning the ‘depth’ of self-knowledge that can be assessed in this way.
Another approach to assess insight has been the use of patients’ appraisals
of specific vignettes (Sargent, 1953; Tolor & Reznikoff, 1960). In the method
developed by Tolor and Reznikoff (1960), for example, 27 hypothetical situations
depicting the use of common defence mechanisms were constructed. For each situ-
ation, four possible explanatory statements were provided and ranked according
to the degree of ‘insight’ they were thought to represent. The test was given to a
sample of 68 inpatients with various psychiatric diagnoses (schizophrenia, neurosis,
personality disorder, etc.) and validated by comparing with independent insight
ratings of patients taken by psychiatrists/psychologists involved in the patients’
care. The authors subsequently reported that patients showed less insight on this test
than untrained nurses who in turn showed less insight than trained nurses. The test
was also used by Roback and Abramowitz (1979), who found that schizophrenic
patients scoring higher, were rated by hospital staff as better adjusted behaviourally
though more distressed subjectively. Interestingly, the use of ‘vignettes’ involving

patients making judgements on hypothetical scenes has been used more recently
as an approach to assess insight in general psychiatry (McEvoy et al., 1993b; Chung
et al., 1997; Startup, 1997). The main problem with such an approach, however,
rests with its assumption that the ability to understand a clinical picture presented,
or the motivations of others as depicted by it, is equivalent or dependent on insight
into one’s self. As was seen above, many writers make an explicit distinction bet-
ween knowledge of self and knowledge of others.
The most common systematic approach taken to assessing insight, particularly
more recently, has been the use of observer ratings generally in the form of judge-
ments based on patients’ statements within psychoanalytic sessions which have
been taped and transcribed. Various measures have been developed (Roback, 1972;
Morgan et al., 1982; Gedo & Schaffer, 1989; O’Connor et al., 1994; Grenyer &
Luborsky, 1996). Crits-Christoph et al. (1993) reviewing some of these methods
point out that although in general inter-rater reliability is much better, the fre-
quent lack of an operationalised definition of insight on which raters can base their
judgements raises questions concerning validity. The main problem with these
approaches is practical in that they tend to be cumbersome and time consuming as
they depend on transcription of taped analytic sessions, and the coding and inter-
preting of individual statements. In addition, as Kivlighan et al. (2000) point out,
insight may develop over a longer time frame than that captured by single client
utterances. Some researchers have used ratings of insight provided by the ther-
apists themselves (Gelso et al., 1991; 1997) which has been more practically con-
venient but raises problems of reliability (as well as biases) since therapists only
rate their own patients. In addition, the global ratings of such methods make it dif-
ficult to specify which aspects of patients’ utterances or behaviours have contributed
to the rating. Interestingly, Grenyer and Luborsky (1996) found no association
between insight as assessed by a global judgement on the part of an observer (and
by the therapist) and their Mastery Scale which incorporated assessment of insight
within its complex rating system. They suggested that it was the difference between
assessing a complex concept such as insight on the basis of a global judgement
compared with its assessment in a specific structured way with reference to indi-
vidual statements. The Insight Rating Scale as used by Morgan et al. (1982) is based
on the definition of emotional insight as proposed by Reid and Finesinger (1952).
It includes nine categories of behaviours (e.g. patient is able to relate present events
to past events, patient recognises particular behaviours as indications of defensive-
ness or resistance, etc.) each of which are rated on a 10-point Likert scale and judged
from transcripts of analytic sessions. The scale was found to have good inter-rater
reliability and internal consistency. Increasingly sophisticated methods in terms of
systematically assessing insight (and other factors important in psychoanalytic and
cognitive-behavioural therapies) on the basis of transcribed statements (and their

contexts) with specific guidance for clinical judgement have since been developed,
e.g. Core Conflictual Relationship Theme (CCRT) (Crits-Christoph et al., 1993) or
the Therapeutic Focus on Action and Insight (TFAI) (Samoilov et al., 2000).
Results of studies exploring the role of insight in psychoanalytic therapies including
comparative studies with other ‘curative’ factors as well as with other psychotherapies
have been mixed. Earlier studies reported very little role for insight as a therapeutic
factor. For example, no relationship was found between levels of insight and outcome
(in terms of individual adjustment) in subjects engaged in three different group
experiences (Mann & Mann, 1959). Another study found that interaction group ther-
apy (i.e. group treatment focused on inter-patient verbal communication and rela-
tions with no reference to psychological problems or personal difficulties) was more
effective in producing improvement than insight-oriented group therapy in ‘mostly
schizophrenic’ hospital in-patients (Coons, 1957). Individual systematic desensitisa-
tion was reported as determining more significant and lasting reduction in mal-
adaptive anxiety than individual insight-oriented psychotherapy in undergraduate
students with interpersonal performance anxiety (Paul, 1967). Reinforcement ther-
apy (i.e. adaptive behaviours reinforced by various rewards) resulted in more signifi-
cant improvement (hospital adjustment scale) in chronic schizophrenic patients
than therapy promoting insight-interpretative statements and fostering of transfer-
ence (Hartlage, 1970). Bogetto and Ladu (1989) reported symptomatic improve-
ment both in patients receiving psychoanalytic psychotherapy and in those receiving
psychopharmacological treatment although patients undergoing psychotherapy
exhibited more insight. None of these studies, therefore, showed any significant role
for insight in determining clinical outcome. However, all these studies are limited by
the sorts of methodological problems as detailed above by Roback (1971; 1974).
Thus, insight tends not to be well defined and it is not clear from the reports if
patients receiving the different forms of insight-oriented therapy actually attained
insight nor how insight was measured, etc.
Some studies have suggested that insight-oriented psychotherapies are likely to
benefit only some individuals and sought to determine factors which might predict
good response (Abramowitz & Abramowitz, 1974; Persson & Alström, 1983; 1984)
but again findings are mixed and similar methodological problems apply.
Reviewing outcomes between insight-oriented and other forms of psychothera-
pies, Luborsky et al. (1993) conclude that whilst insight-oriented psychotherapy
seems to result in significant change in most patients, other treatments appear to
obtain similar effects in relation to outcome. In other words, the specific role of
insight remains unclear.
More recently, studies employing specifically defined and systematic methods of
assessing insight have also yielded variable results. Some studies suggest that
patients’ insight seems to develop linearly as therapy proceeds (Gedo & Schaffer,
1989; Grenyer & Luborsky, 1996; Kivlighan et al., 2000). Others report that
patients’ insight seems to follow a quadratic curve during the course of therapy, i.e.
higher insight found at the beginning and end of treatment with a reduction in
insight apparent during the middle of treatment (O’Connor et al., 1994). The
Kivlighan et al. (2000) study also found an association between higher insight and
a greater reduction of complaints in 12 clients undergoing psychoanalytic psy-
chotherapy. Other studies, however, have not found such a specific relationship
between insight and outcome. In fact, most studies seem to suggest that it is the
combination or interaction of insight and other factors that seems to determine
positive outcome. For example, in the study by Morgan et al. (1982), patients’
perceptions of the therapeutic relationship with their analysts were predictive of
positive outcome. Although patients’ insight correlated with the measures of thera-
peutic alliance, insight on its own did not predict outcome. Similarly, other studies
have specified the combination of insight with other factors such as interaction
(Roback, 1972), transference (Gelso et al., 1991; 1997) or ‘mastery’ (i.e. emotional
self-control as well as self-understanding) (Grenyer & Luborsky, 1996) as being
associated with improved outcome.
2.2.3 Summary
It can be seen that a range of views are held concerning the definition of insight
and approaches taken to its classification and to its empirical assessment. What is
apparent from the various conceptualisations, however, is that psychoanalytic
insight, in its broad sense, and particularly in comparison with conceptualisations
of insight in other disciplines, emerges as a specially complex phenomenon. This
complexity stands out because it relates not only to the content of the concept itself
but also to its singular position within the structure of the psychoanalytic dis-
cipline. Furthermore, these two aspects of psychoanalytic insight are inextricably
linked. As far as the content of the concept is concerned, its striking feature relates
to the depth of knowledge that is invoked. This depth is apparent in two aspects
relating to the concept. Firstly, it refers to a self-knowledge that is beyond ‘normal’
awareness or self-observation but reaches preconscious and unconscious mental
states. This immediately raises complex problems relating to the epistemology of
such unconscious mental processes. Thus, insight in the Gestalt and cognitive
fields involves knowledge of problem solutions that are more or less directly
verifiable. Insight in general psychiatry (Chapter 3) and in neurological states
(Chapters 4 and 5) involves knowledge of illness/disability that is inferred from
patients’ verbal utterances which are subsequently matched with professionals’
judgements of illness. In these other conceptualisations of insight, the validity of
the knowledge that can be determined, in terms of its extent, its limitations and
underlying assumptions, is more easily delineated (at least in theory). Knowledge

of unconscious mental processes, in contrast, presents special difficulties in this
regard. The most obvious one concerns the question of validity or truth, i.e. to
what extent can knowledge of unconscious mental processes as presented in the
understanding and acceptance of interpretations be considered correct? And, what
does ‘correct’ mean in this context? Some writers, for example, insist that inter-
pretations must be ‘correct’ (Bibring, 1954; Blum, 1979; 1992; Segal, 1991) and oth-
ers claim that this is not necessary (Reid & Finesinger, 1952; Roback, 1974). At any
rate, this issue raises major difficulties and has to some extent contributed to the
circularity alluded to previously with respect to the relationship between insight
and change. In other words, it is generally assumed that when an individual attains
some degree of insight, this knowledge becomes integrated within the person’s ego
or personality such that the individual experiences some form of change –
variously described in terms of subjective, intrapsychic, clinical, etc. At the same
time, however, it is on the basis of the change itself that the individual is said to
have attained insight.
Secondly, the depth characterising psychoanalytic insight is also apparent in the
way in which the knowledge is attained. As writers have attempted to define in vari-
ous ways, whether termed mutative, emotional, interpretative or ostensive insight,
the emphasis has been on the individual somehow experiencing directly within
him/herself this knowledge. This experience is clearly more than the ‘Aha’ experi-
ence described in the Gestalt literature for it refers to an experience that involves
understanding of unconscious material that can be related to the present and
hence the resulting reorganisation/restructuring reaches depths or dimensions
that are not considered in Gestalt psychology.
In addition, the concept of psychoanalytic insight occupies a central and inte-
gral position within the psychoanalytic discipline which contributes to the special
complexity surrounding psychoanalytic insight. This is evident from the role
insight has played in the development of, the goals set, and the methods employed
by the discipline. In particular, in the case of the latter, the unique dialectic within
the patient–analyst relationship stands out as the distinctive element that serves to
both deepen the concept of insight and at the same time intrinsically relates to the
structure of the psychoanalytic discipline itself.
This complexity surrounding the conceptualisation of psychoanalytic insight
has undoubtedly contributed to the limited empirical research in this area. Major
difficulties arise in attempting to operationalise a concept that contains such elu-
sive components as unconscious material and experiential elements. In addition,
attempting to separate insight from other analytic concepts including the ‘real’ and
the ‘analytic’ attitudes/actions of the analyst and the interaction itself between
patient and analyst raise further empirical problems. Hence, results of empirical
studies exploring the role of insight in promoting change are variable and the
specific role of insight remains to be determined.
2.3 Conclusion
The conceptualisations of insight from the particular perspectives of Gestalt, cog-

nitive and psychoanalytic psychological schools of thought, whilst sharing several
similarities, are also profoundly different. Superficial similarities can be recognised
from some of the terminology used in common such as ‘restructuring’ or ‘reorgan-
isation’, albeit, that these terms refer predominantly to external events in the case
of the Gestalt and cognitive psychologies, and to internal events in the case of psy-
choanalytic psychologies. In addition, some similarities have also been identified
in a few empirical approaches based on a shared conception of insight as an ‘event’
culminating from various postulated stages (framed either in terms of mental
preparation/incubation or ‘working through’).
Crucial differences emerge, however, between the conceptualisations of insight
as developed from the various psychological perspectives. As was seen, the Gestalt
and cognitive notion of insight as a specific discrete and sudden phenomenon con-
trasts strongly from the ongoing, limitless process conceived by the psychoanalytic
school. The most obvious difference, however, concerns the relational aspect of
insight in the two broad schools of thought. Thus, insight, in Gestalt and cognitive
psychology refers to a specific form of knowledge or understanding in relation to a
particular problem outside the individual. The problem may be restructured such
that a solution is understood and experienced by the individual, but that under-
standing refers to the outside problem. Insight in psychoanalytic psychology, on
the other hand, refers to a specific form of knowledge or understanding in relation
to a particular state or problem within the individual. Understanding the self, i.e.
one’s conscious and unconscious mental processes, results in the restructuring of
the psyche. Whatever way knowledge or understanding is framed, clearly, there are
significant differences between the sorts of knowledge involved in relation to the
external world and the sorts of knowledge involved in relation to the self. These
differences are likewise reflected in the empirical evaluation (and determination)
of insight in relation to the different disciplines.
In addition to differences in conceptualisations of insight between the psycho-
logical disciplines, there are differences apparent within the individual disciplines,
in terms of views on specific definitions, underlying processes, importance of
insight in the context of other mental processes, empirical approaches taken to its
assessment and relationship to external factors. As in other areas, such differences
are likely to reflect the inherent complexities surrounding the concept of insight as
a form of knowledge irrespective of the framework in which this is embedded.
The psychological perspectives on insight are important to consider because

they have been and continue to be influential in conceptualisations of insight in
clinical psychiatry. The Gestalt and cognitive psychology views have been particu-
larly important in relation to much of the work on insight and awareness in
organic brain syndromes such as dementias especially in terms of some of the
empirical approaches taken to assess awareness and implicit awareness (Chapters
4 and 5). Crucially, the role of metacognitions in determining insight is different
when applied to cognitive psychology problems than when applied to clinical prac-
tice, i.e. in eliciting insight in neurological conditions. This carries implications for
how insight is understood and differentiated in these areas. Psychoanalytic psych-
ology views were inherent to some of the earlier empirical studies on insight in
psychiatry at a time when this school of psychology was particularly dominant
within clinical psychiatry as a discipline. As the disciplines diverged, psychoana-
lytic views on the nature of insight as a deep knowledge of unconscious mental
processes have persisted in various forms. The usage of the concept of denial, for
example, prevalent in studies on insight both in general psychiatry and in organic
brain syndromes, refers specifically to the activity of unconscious mental processes
to which an individual has no access.
3
Insight in clinical psychiatry: empirical studies
Until relatively recently, there has been little interest in the empirical exploration of
insight in clinical psychiatry. However, over the last 10–15 years, increasing numbers
of studies have focused on this area. Such studies have, predominantly, set out to
examine the relationship between patients’ insight and clinical variables, such as prog-
nosis (McEvoy et al., 1989a; Amador et al., 1993), treatment compliance (e.g. Bartkó
et al., 1988; Buchanan, 1992; Cuffel et al., 1996; Mutsatsa et al., 2003) and severity of
psychopathology (e.g. McEvoy et al., 1989b; Amador et al., 1993; 1994; Carroll et al.,
1999; Goldberg et al., 2001; Drake et al., 2004), and have concentrated mainly on
examining this in patients with psychoses (Amador & David, 1998). More recently,
a number of studies have explored the relationship between patients’ insight and
neuropsychological impairment (e.g. Young et al., 1993; 1998; Cuesta & Peralta, 1994;
Lysaker et al., 1994; 1998a; 2002; Marks et al., 2000; McCabe et al., 2002; Mintz et al.,
2004) and, indeed, structural brain lesions as assessed, e.g. by magnetic resonance
imaging (MRI) (Takai et al., 1992; Flashman et al., 2001; Rossell et al., 2003). Much of
this work has yielded, as will be shown in this chapter, somewhat mixed and inconsist-
ent results. Consequently, the relationship between patients’ insight and various clin-
ical variables remains unclear (Marková & Berrios, 1995a, b). Various measures to
assess insight have been developed (e.g. McEvoy et al., 1989b; David, 1990; Amador
et al., 1991; Marková et al., 2003), suggesting that perhaps they capture different
aspects of insight and this might contribute to some of the variability in results.
This chapter reviews the empirical work carried out in this area and focuses on
identifying and defining some of the general and specific difficulties inherent to the
clinical exploration of insight. Firstly, the different definitions of and approaches
to assess insight in the various studies will be examined. Secondly, the results of
studies exploring the relationship between patients’ insight, and clinical and socio-
demographic variables will be reviewed and discussed in the context of the conceptual
and methodological problems of exploring patients’ insight empirically.
3.1 Definitions of insight and methods of assessment
One of the most striking issues emerging from review of empirical work on insight
is the absence of a consistent definition of insight and means by which it is
66
67 Insight in clinical psychiatry: empirical studies
assessed. In fact, there are two separate problems inherent to this issue. First, and
obvious, is the variability itself in definitions of insight and methods of insight
assessment, which clearly carries implications for making meaningful compari-
sons between studies. However, second is also the question of the extent to which a
particular insight measure reflects the definition or concept of insight on which it
is based. This problem more specifically has to do with the difficulties in translat-
ing from a complex concept to a measure that can capture the identified compon-
ents in a clinical form and hence raises different sorts of issues. In general, methods
of assessing insight can be broadly divided into those involving (i) categorical, and
(ii) continuous approaches.
3.1.1 Categorical approaches to exploring insight

Most of the earlier empirical studies assessing the insight in patients with mental ill-
ness use categorical approaches, dividing patients into those with and without
insight, and those with some or partial insight. The numbers of categories vary
from a simple insight/no insight division (e.g. Van Putten et al., 1976) to several cat-
egories designed to capture a hypothetically determined progressively graded
amount of insight (e.g. Linn, 1965). Categorical measures are useful in allowing
comparisons to be made between individuals on broadly defined characteristics but
there are two main disadvantages with such approaches. Firstly, the distinctions
between different categories are often difficult to determine (Eskey, 1958; Heinrichs
et al., 1985; Bartkó et al., 1988, Dittman & Schüttler, 1990) hence casting some
doubt on their reliability. On the other hand, some categorical approaches to insight
assessment, as well as to general psychopathology evaluation, try to counter this
problem by providing relatively specific criteria to help determine the appropriate
category (e.g. insight items 104 and 105 on the Present State Examination, PSE
(Wing et al., 1974)). Secondly, there is the problem concerning the meaning that can
be inferred from categorical descriptions. This incorporates a number of separate
issues ranging from the general problems of categorisation and the relationship
between categories when these are given ratings (e.g. is the ‘distance’ between cat-
egories 1 and 2 the same as between categories 2 and 3?) to the specific problems con-
cerning how much of the underlying concept is actually captured by the categories.
Examining some of the studies on insight illustrates a number of these problems.
The studies by Van Putten et al. (1976) and Heinrichs et al. (1985) both cat-
egorised patients into those with and without insight. The former study used a
definition of insight according to which the patient acknowledged some degree
of awareness of emotional illness. The latter defined insight as a recognition on the
part of the patients that they were beginning to suffer a relapse of their psychotic
illness. In both the studies, the fairly broad notions of insight are in fact reduced by
the categorisation into all-or-none concepts and any detail concerning the type or
degree of awareness or recognition is inevitably lost. Whitman and Duffey

(1961) refer to the patient’s ‘perception of illness,’ which again implies a fairly
broad concept. Their translation of this into two categories, namely, patients
expressing a functional reason for hospitalisation (e.g. feeling mixed up, having no
control over thinking), and patients expressing a non-functional reason for hospi-
talisation (e.g. due to physical problem, being punished, etc.), however, suggests a
narrower concept focused selectively on the attributed cause of hospitalisation
rather than on subjective feelings of illness. Lin et al. (1979) defined insight as the
patients’ recognition of problems and the need for medical help. The authors
translated this concept into a structured assessment based on three questions con-
cerning whether patients thought they had (1) to be in hospital, (2) to see a doctor
or (3) to see a psychiatrist. Patients were categorised as having insight if they
answered affirmatively to any one of the questions. Again the relationship between
the definition of insight and the assessment of insight is not straightforward here.
Firstly, there is the assumption that recognition of existence of problems is equiva-
lent to recognition of needing help. Secondly, affirmative answers to needing
hospitalisation/doctors (without further exploration) may not necessarily reflect
recognition of either having problems or needing medical help as they may include
delusional ideas or motivational factors contributing to the responses. Clearly,
there are difficulties in trying to capture the full content of definitions of insight
into limited numbers of categories.
The concepts of insight held in these earlier studies vary in focus. Some define
insight on the basis of acknowledged change in intellectual (Eskey, 1958) or emo-
tional (Van Putten et al., 1976) problems. Insight is thus conceived broadly and it
is sufficient for patients to appreciate some disturbance in their mental states.
Dittman and Schüttler (1990), using the term ‘disease-consciousness’, hold a simi-
lar concept of insight though slightly more focused in defining it in terms of some
awareness of the existence of psychotic behaviour. They conceive this as a first step
in gaining control over psychotic symptoms, thus contrasting with the more ‘pas-
sive’ conceptions of insight held by the early alienists (Chapter 1), and giving this
a more active role in coping strategies employed by patients. Other definitions of
insight demand more specifically the recognition of illness (Hankoff et al., 1960;
Wing et al., 1974; Heinrichs et al., 1985). In other words, patients need to not only
acknowledge mental problems but also to interpret these as being the result of
mental illness. More specificity still is required by definitions of insight which
incorporate, in addition, the recognition by patients that they need medical inter-
vention whether this is hospitalisation (Linn, 1965; Lin et al., 1979) or treatment
(Bartkó et al., 1988) or both (Small et al., 1964; 1965). Thus, a more precisely delin-
eated conception of insight is held in these latter definitions, selectively focusing
on the judgements of mental illness and the need for treatment.
From a different perspective, and based on Mayer-Gross’ classification of

patients’ reactions to psychoses, Soskis and Bowers (1969) categorised patients into
those with negative and positive attitudes towards their illness. In fact, they were
conceiving a much wider notion, which contained attitudes towards insight (itself
defined as understanding of problems) within a broader framework of patients’
feelings about what was happening to them. However, it illustrates some of the
difficulties inherent in the terminology itself when examining the meanings of
insight and related notions. Thus, whilst e.g. Lewis (1934, (see Chapter 1)) used the
term ‘attitude’ to refer to awareness and judgement made of the experience by the
patient, Soskis and Bowers (1969), on the other hand, use this term to refer to value
judgements; i.e. personal reactions to their judgements of their experiences. A simi-
lar approach (and likewise influenced by Mayer-Gross) was taken by Wciórka
(1988) who categorised schizophrenic patients according to the type of attitude
they held towards their illness. He conceptualised such attitudes broadly and dis-
tinguished between three types of composite attitudes: (1) isolating: where patients
did not identify their illness with themselves, they evaluated it negatively and
reacted in a non-reflective way; (2) integrating: where patients identified the illness
with themselves, evaluated it positively and showed a reflective way of reacting to
it and (3) undecided: where patients responded in a vague and incoherent fashion.
Thus, these attitudes captured a wider complex of judgements and reactions to
patients’ experiences than some of the other notions relating to insight. Other dif-
ferent conceptualisations of insight, also emerging particularly in some of the earl-
ier studies, relate to the psychoanalytic concept of denial, framed either in
Freudian terms (O’Mahoney, 1982) or following Weinstein and Kahn’s (1955)
influential work (see Chapter 4) (Kahn & Fink, 1959). However, this clearly
represents yet another conceptualisation of insight, incorporating the notion
that understanding or knowledge is actively withheld from the self. Various empir-
ical measures of denial following this line of thinking were devised and patients
were generally categorised on the basis of scores on the rating scales (e.g. Kahn &
Fink, 1959).
3.1.2 Continuous approaches to exploring insight

More recently, the other main approach to studying insight empirically has involved
the conceptualisation of insight as a continuous process rather than the all-or-none or
partial concept described above. Attempts have focused on assessing insight in a
graded manner and using structured schedules in order to capture quantitatively in
more detail some of the explicitly defined components of insight. However, some of
the problems arising in relation to the categorical approaches to studying insight are
equally pertinent here. Thus, there are differences in the definitions of insight between
studies and likewise between the measures used to capture these; and, similarly, the
extent to which such measures reflect the concept of insight held varies between the
different studies.
McEvoy et al. (1989a, b, c) were amongst the first to develop a standardised ques-
tionnaire to assess insight in psychotic patients as a continuous process and defined
it in terms of a correlation between the judgements made by patients and those made
by clinicians. They maintained that, ‘patients with insight judge some of their per-
ceptual experiences, cognitive processes, emotions or behaviors to be pathological in
a manner that is congruent with the judgement of involved mental health profes-
sionals, and that these patients believe that they need mental health treatment, at
times including hospitalization and pharmacotherapy’ (McEvoy et al., 1989b, p. 43).
Translating from this concept to an empirical measure, the ‘Insight and Treatment
Attitude Questionnaire’ (ITAQ), they focused on two aspects of their definition.
Firstly, the questions in the measure relate specifically to patients’ attitudes towards
the need for hospital admission, for medication and for future follow-up. Secondly,
the ratings of insight are based explicitly on the extent to which the patient is in
agreement with the mental health professional concerning such attitudes. As a result,
the empirical concept of insight captured by this measure emphasises more the (con-
cordant) views patients have concerning their management rather than any detailed
understanding they have concerning specific morbid experiences. The ITAQ
(11 questions: score range from 0 (no insight) to 22 (maximum insight)) was val-
idated against taped open interviews and was shown to correlate well with clinicians’
judgements of patients’ insight but it clearly reflects this specific and narrower
empirical perspective borne out also by its single factor structure.
A broader conceptualisation of insight is offered by Greenfeld et al. (1989) fol-
lowing an exploratory study of patients’ views concerning their psychotic experi-
ences. They propose a model of insight consisting of five distinct and independent
dimensions relating to: (1) views about symptoms, (2) views about the existence of
an illness, (3) speculations about aetiology, (4) views about vulnerability to recur-
rence and (5) opinions about the value of treatment. Their semi-structured inter-
view addresses each of these areas and insight is described qualitatively and
separately in each domain. Thus, the conception of insight here, both in defin-
itional terms and in its empirical evaluation, is focused more on patients’ under-
standing of what is happening to them and what individual sense they are making
of their experiences. As such, this represents a wider structure of insight. In empir-
ical terms the qualitative capture of these components makes it difficult for ‘rat-
ings’ of insight to be determined and hence comparisons between patients or
patient groups are more cumbersome.
Other multidimensional models of insight have been proposed by David (1990)
and Amador et al. (1991; 1993) and, in both, the emphasis lies in the translation
from the models to structured empirical measures that rate insight quantitatively.
David (1990) conceives insight in psychotic patients as composed of three distinct

though overlapping dimensions, namely: (1) recognition that one has a mental ill-
ness, (2) compliance with treatment and (3) the ability to relabel psychotic events
(delusions and hallucinations) as pathological. Thus, the predominant focus in
this definition lies in the acknowledgement of illness and needing treatment as well
as a judgement concerning the morbid nature of delusions and hallucinations.
This narrower and specific conception of insight lends itself to a more direct and
quantifiable translation into an empirical measure. Hence, David’s Schedule for
Assessing Insight (SAI) reflects very closely the defined dimensions and patients are
rated according to the extent to and/or frequency with which they accept they are
ill, need treatment and judge their psychotic phenomena as real (total score range
0–14; (David, 1990)). Similarly, the Insight Scale (IS) devised by Birchwood et al.
(1994) is an alternative direct translation from David’s three-dimensional model
of insight but in this case the empirical form is presented as a self-report measure
(scoring 0–4 on each dimension, maximum: 12).
A more complex multidimensional model of insight is proposed by Amador
et al. (1991). Based on an analysis of the variety of ways in which insight and related
terms are used within the psychiatric literature, they conceive insight as comprising
of (1) awareness of the signs, symptoms and consequences of illness, (2) general
attribution about illness and specific attribution about symptoms and their conse-
quences, (3) self-concept formation and (4) psychological defensiveness. Clearly,
this represents a wider and more detailed structure of insight which incorporates
comprehensively views on individual experiences and being ill, as well as including
additional components relating to judgements about effects of such experiences
and views relating more broadly to understanding of the self and the self ’s psycho-
logical processes. Recognising the practical difficulties in translating from such a
wide and complex construct to an empirical measure of insight, Amador and
Strauss (1993) narrowed this concept further to one comprising two salient com-
ponents: (1) awareness of illness and (2) attribution regarding the illness. This con-
cept thus picks up on the same dimensions or components identified by many of
the earlier alienists and psychiatrists (e.g. Billod, 1870; Parant, 1888; Jaspers, 1948;
see Chapter 1). The empirical measure based on this concept, the Scale to Assess
Unawareness of Mental Disorder (SUMD) (Amador et al., 1993) teases out in detail
these components and this is reflected in the instrument consisting of 6 general
items and 4 subscales from which 10 summary scores can be calculated (scores
ranging from 1 to 5 on each item). The general items rate current and retrospective
views around global awareness of mental disorder, awareness of achieved effects of
medication and awareness of the social consequences of having a mental disorder.
The four subscales (consisting of 17 items each) rate awareness and attribution of
specific symptoms, signs and deficits (e.g. thought disorder, alogia and anhedonia,
etc.), and again include separately both current and retrospective views. Thus, this
is a comprehensive clinician-rated measure and, when used in its full form, places
emphasis on the judgements made by patients concerning the nature of their indi-
vidual symptoms. In turn, this is dependent on patients experiencing or showing
the symptoms/signs in question. However, the authors make it clear that the items
and scales can be used independently according to the need of investigators and in
that sense the phenomena of insight elicited will necessarily vary depending on the
scale/item employed. This is because the emphasis can change from rating a general
awareness of being ill, and needing treatment to a more specific awareness and attri-
bution of particular signs. For example, in their large study examining insight in
412 patients, Amador et al. (1994) used an abridged version of this instrument in
which items relating to retrospective awareness and attribution regarding illness
and symptoms were removed. Clearly, from a practical perspective it is not always
possible to evaluate insight in the full detailed and comprehensive way demanded
by the instrument but at the same time it is important to acknowledge that when
the different components of the instrument are used independently they do not in
themselves reflect the overall broad conceptualisation of insight that was the source
of the empirical instrument but, instead, elicit different aspects of insight as origin-
ally defined. However, the structured nature of the measure allows for the different
aspects of insight as captured by the independent components to be clearly defined
and demarcated.
Partly to avoid some of the complexities involved in measuring insight with the
above multidimensional models much of the empirical work on insight in psych-
iatry has used insight ratings taken from specific insight items within more general
psychopathological assessments, such as the PSE (Wing et al., 1974), the Manual
for the Assessment and Documentation of Psychopathology (AMDP) (Guy & Ban,
1982) and particularly, the insight item from the Positive and Negative Syndrome
Scale (PANSS) (Kay et al., 1987). Within these structured psychopathological
measures, insight is assessed along the same scales of increasing/decreasing sever-
ity as the other ‘symptoms’ or ‘signs’. Thus, the ‘lack of insight and judgement’ item
in the PANSS is rated from 1 (absent: no lack of judgement) to 7 (extreme:
emphatic denial of past and present psychiatric illness), with intermediate ratings
in between, in the same way that other ‘symptoms’ are rated as absent to extreme.
Similarly, the insight item in the PSE is rated along a 4-point scale of severity
(0 full insight, 3 denies condition entirely) in line with other ‘symptoms’ in
the schedule. Such measures are useful in that they are practical and simpler to
score but they lack the capacity to capture details of insight content and, despite
the scoring systems, are basically categorical assessments of severity.
A different approach to evaluating patients’ views about their illness was taken
by Carsky et al. (1992) who devised a self-report scale. Rather than concentrating
on insight as such, they based their instrument on a concept spanning acknow-

ledgement and denial of illness in hospitalised psychiatric patients. In this context,
they focused on a narrow definition of denial, specifically limiting this to a failure
to acknowledge: (1) having an illness or that the illness has a name or a cause,
(2) any need for hospitalisation and (3) that the illness has personal impact (Carsky
et al., 1992, p. 459). Their Patient’s Experience of Hospitalization (PEH) is an
18-item (each item rated on a 4-point scale of severity or level of agreement with a
higher total score indicating greater denial) self-report scale which reflects pre-
dominantly views about being in hospital (e.g. whether this is necessary, whether
there can be gain from hospitalisation, etc.) and the degree to which the patient
worries about his/her condition. Thus, the focus of the concept, and reflected in
the empirical measure used, is less on the actual understanding patients have con-
cerning their individual experiences and the sense they make of these but more on
their general responses or reactions to their situations, as well as their views on the
benefits of being in hospital.
Using the same concept but broadening it to some extent, Marks et al. (2000)
devised their Self-Appraisal of Illness Questionnaire (SAIQ) based closely on the
PEH but designed for use in community settings. Thus, again focusing on attitudes
towards illness rather than perception of experienced changes, the SAIQ is a
17-item self-report scale following the format of the PEH but substituting items
about hospitalisation with similar items relating to the need for treatment. A fac-
tor analysis of the SAIQ yielded three factors reflecting the specific foci of the con-
cepts used, namely: (1) need for treatment, (2) worry about condition and (3)
presence/outcome of illness. Predictably, the authors found correlations between
the need for treatment and presence/outcome of illness subscales with specific
clinician-rated measures of insight including the abridged form of the SUMD
(Amador et al., 1994). Interestingly, they found no correlation between their worry
subscale (items relating to patients worries about their condition) and clinician-
rated measures of insight indicating that perhaps different aspects of the concept
were being elicited. The authors themselves speculated that perhaps the worry
items, by picking up on patients’ reactions or coping mechanisms, were addressing
components of insight that were not being captured by the other (clinician-rated)
measures of insight.
Our own work, also following a continuous approach to assessing insight,
developed a self-rating insight questionnaire designed to evaluate insight in
patients with psychoses (Marková & Berrios, 1992b; Marková et al., 2003). Based
on Hamlyn’s (1977) ideas on self-knowledge, as well as conceptual analysis of the
way in which insight was understood in the psychiatric literature, a broad concept
of insight was proposed as a sub-category of self-knowledge patients hold not only
about the disorder affecting them but also how the disorder affects their interaction
with the world (Marková & Berrios, 1992a, b; Marková & Berrios, 1995a, b). In
other words, the concept here focuses on awareness of changes to the self (and how
this affects perceptions of and interactions with one’s world) in relation to the
pathological state affecting the patient. In terms of conceiving insight as a continu-
ous process, the issues behind this particular concept of insight were, firstly, to
capture the intermediate stages of experienced change in the patient, i.e. before the
judgement was reached (if ever) that the changes represented a particular mental
illness and, secondly, to focus more on changes in perceptions of altered self. The
empirical measure, the Insight in Psychosis Questionnaire (IPQ), translated from
this broad concept of insight, consists of 30 items chosen on face validity grounds
(clinical observation together with clinical descriptions (e.g. Conrad, 1958)), to
reflect awareness of possible changes that individuals might experience during the
course of a psychotic episode. Following piloting of the IPQ (Marková & Berrios,
1992b), some items were re-phrased, some were deleted (those relating to views
about hospitalisation and taking medication) and the scoring was simplified to a
dichotomous (agree/disagree) form, and the resultant measure was subsequently
re-standardised (Marková et al., 2003). Clearly, this measure is thus eliciting very
different aspects of insight compared to most of the previous assessments where
the focus was specifically on judgements of mental illness and judgements concern-
ing the need for medication/treatment.
Finally, interesting approaches to assess insight have included the use of
vignettes describing various pathological states (e.g. McEvoy et al., 1993b; Chung
et al., 1997) and discrepancy measures, i.e. the difference in ratings made by
patients and their relatives (e.g. Exner & Murillo, 1975; Taylor & Perkins, 1991;
Dixon et al., 1998). The latter are much less often used generally in psychiatry
compared with empirical studies on insight in patients with neurological states
(Chapters 4 and 5). In the case of vignettes, insight is determined according to
views expressed by patients in relation to the content of the vignettes, e.g. the
extent to which patients feel the vignettes resemble their own clinical states
(McEvoy et al., 1993b) or whether the contents represent mental disorders
(Startup, 1997) or both (Chung et al., 1997). Insight is thus assessed indirectly in
that the phenomenon that is elicited is construed of judgements made in relation
to third-person scenarios with or without further judgements made concerning
any resemblance between such scenarios and patients’ own subjective experiences.
Similar issues to those raised in the review of insight measures used in psychoana-
lytic studies (Chapter 2) apply here. Thus, the aspects of insight captured by this
type of assessment, where patients’ judgements are demanded of external events,
will necessarily be different from insight that focuses on judgements made con-
cerning patients’ views of themselves. The use of a vignette depicting an individual
with psychotic symptoms given to a sample of the general population (Lam et al.,
1996) as well as in schizophrenic patients, relatives and the general public (Chung
et al., 1997) raised another important issue in terms of conceptualising insight.
Both the above studies reported a low recognition of mental illness and the need
for treatment in general public subjects who were given the vignette. Indeed,
recognition of illness and need for treatment was slightly higher (and hence insight
in those terms better) in patients and relatives compared with the general public
(Chung et al., 1997). This led the authors to highlight the need to consider patients’
insight in the context of the background knowledge or understanding of the soci-
ety and culture they lived in before attributing any impairment of insight to the
psychotic process. Startup (1997) found no association between schizophrenic
patients’ insight as assessed by the ITAQ and their judgements’ of others’ mental
disorder on the basis of vignettes suggesting that these different methods of assess-
ing insight involved independent judgements. This is an important complicating
factor in terms of conceptualising insight and illustrates the need to view insight as
a multidimensional structure rather than solely as a symptom that can be related
to a disease process (see Part II).
3.1.3 Summary of empirical assessments of insight

It has been shown that empirical studies in clinical psychiatry employ diverse
methods to assess patients’ insight, based on a range of definitions. It is worth reit-
erating some of these differences, which affect definitions, assessment methods
and the relationship between them.
3.1.3.1 Definitions
As is evident, definitions of insight vary in terms of specificity, breadth, focus and
complexity. Some studies define insight very specifically e.g. as the recognition of
being mentally ill (Wing et al., 1974; Heinrichs et al., 1985) whereas other studies
use more general definitions such as the recognition of some mental disturbance
(Eskey, 1958; Van Putten et al., 1976). Some studies conceive insight narrowly in
terms of considering views only about illness (Heinrichs et al., 1985; Dittman &
Schüttler, 1990) whilst others broaden the concept to include a range of views
about any experienced changes and about effects of the disturbance on the self and
functioning (Greenfeld et al., 1989; Amador et al., 1991; Marková & Berrios,
1992a). The emphasis in the definitions varies in the studies with some focusing
primarily on the acknowledgement of illness and/or the need for medical treat-
ment (Lin et al., 1979; Bartkó et al., 1988; McEvoy et al., 1989b), and others focus-
ing more on the sense patients are making of their experiences and the effects of
these on themselves (Greenfeld et al., 1989; Marková & Berrios, 1992a; Marková
et al., 2003). And, the complexity of the concepts varies in studies with some defin-
ing insight in fairly simple terms such as a judgement concerning what is happening
to patients (Eskey, 1958; Wing et al., 1974) whilst other studies propose more com-
plex concepts which include a number of judgements or components relating to
different aspects of their experiences (Greenfeld et al., 1989; David, 1990; Amador
et al., 1991). Moreover, in all these respects, the level to which such definitions are
delineated is also variable. For example, the individual components of the concept
of insight in David (1990) and Amador et al. (1991) are clearly defined and demar-
cated. On the other hand, the broad concept of insight proposed in our work
(Marková & Berrios, 1992a) lacks defined boundaries and, hence, the extent of
knowledge or understanding patients are required to have concerning their condi-
tion and its effects in order to be deemed insightful is less clear.
3.1.3.2 Assessments
Assessment methods differ in a number of ways as well. Firstly, they differ in how
closely they reflect the researchers’ concept of insight. Where there does seem to be
a close match between the original definition and the measure itself, then the same
differences as described above, between the ways in which insight is defined, apply
to the assessment methods themselves. Additionally, differences can be identified
between the ways in which insight is captured and rated. Thus, the main difference
lies between methods using a categorical approach to rate insight (Eskey, 1958;
Small et al., 1965; Van Putten et al., 1976; Heinrichs et al., 1985) and those using a
continuous approach (McEvoy et al., 1989; David, 1990; Marková and Berrios 1992b;
Amador et al., 1993). Categorical assessments are simpler to use and generally
patients can be rated as having insight, not having insight or having partial insight
according to the particular criteria employed. However, judgements are necessarily
cruder in content and the anchor points between categories are often not
clear. Continuous measures on the other hand tend to capture more specific
information but vary in terms of the different components included in the meas-
ures as well as the particular focus (e.g. acknowledgement of illness or need for
medication or awareness of effects, etc.). In addition, further differences exist
between the methods using clinician rating of patients’ insight (Greenfeld et al.,
1989; McEvoy et al., 1989; David et al., 1992; Amador et al., 1993) and those using
self-rating measures (Birchwood et al., 1994; Marks et al., 2000; Marková et al.,
2003). Thus the clinician ratings necessarily incorporate additional factors, which
shape the clinician’s judgements concerning patients’ insight. The self-rating meas-
ures are more direct expressions of patients’ views but do not allow for elaboration
or explanation of answers. Similarly, methods using discrepancy measures involve
assumptions concerning the judgements made by non-affected individuals
and incorporate additional factors relevant to those whilst assessments using
vignettes demand different types of judgements. These issues are explored in detail
in Part II.
3.1.3.3 Implications
The differences in the conceptualisation of insight and in the measures devised to
assess insight, that are clearly present in the studies detailed above, have important
consequences. Firstly, they serve to highlight the difficulties in attempting to define
in a practical sense what is a complex concept. Both the content and the limits or
boundaries of the concept remain ill defined. Secondly, it is likely that, given such
differences in definitions and approaches used to assess insight, different aspects of
insight are elicited and rated in the various studies. This is an essential point as it
means that comparisons between results of the studies will be problematic as it
cannot be assumed that they are all capturing the same insight phenomenon. This
is not to say that the insight measures are all eliciting completely different phe-
nomena. Indeed, most of the studies, which have sought to correlate some of the
insight measures have found generally modestly significant correlations between
different insight assessments (e.g. David et al., 1992; Sanz et al., 1998; Francis &
Penn, 2001) or different subscales/dimensions of the same insight measure (David
et al., 1992; Larøi et al., 2000). However, some studies report more mixed results
with modest correlations between only some subscales/dimensions of insight
measures either with each other (Amador et al., 1993; McCabe et al., 2000) or with
other insight assessments (Marks et al., 2000). It is likely that whilst the various
insight measures may be capturing something that is common to most of them,
there will be, nevertheless, differences between them in the detail of the phenom-
ena elicited. Further support for this claim comes from the finding that in a same
study, different insight measures yield different results as far as relationship to clin-
ical variables are concerned (David et al., 1992; Cuesta et al., 1998; Sanz et al., 1998;
Cuesta et al., 2000). Furthermore, because, as was reviewed, differences between
the insight assessments occur at more than the content level, then comparisons
and generalisations between studies in terms of outcomes become more problem-
atic and it is questionable whether stringent statistical methods such as meta-
analysis (Mintz et al., 2003) may be applied to summarise such studies in a
meaningful way.
3.2 Relationship between insight and clinical and

socio-demographic variables
The question then is what can the empirical studies on insight tell us about the
nature of insight in patients with psychiatric disorders? The increased interest evi-
dent in exploring insight clinically seems to have arisen, in part, following observa-
tions that lack of insight is extremely prevalent in patients with psychiatric illnesses.
Indeed, ‘lack of insight’ was described as the most frequent symptom of schizo-
phrenia in the Report of the International Pilot Study of Schizophrenia (World Health
Organization, 1973). However, the basic question underpinning the empirical stud-
ies exploring insight in relation to patients’ symptoms, illnesses and various socio-
cultural and demographic variables, whether or not this is stated explicitly, is one
concerning the nature of insight as a clinical phenomenon. This question can be
reduced to some primary issues, namely: (i) is lack of insight in mental illness
inherent to the mental disorder, i.e. a product of the disease process and hence to be
considered as a ‘symptom’ in the same way as other illness features or (ii) can insight
be considered a separate or independent mental phenomenon, one that can be
affected by having a mental or other disorder, but also open to the internal and
external influences that determine individual knowledge/beliefs. In effect, this basic
issue is simply a reformulation of the question with which psychiatry has struggled
since the notion of insight was conceived as an independent phenomenon (Chapter 1).
In other words, is it possible for someone with a ‘disordered’ mind to have full
awareness/insight of the disorder itself? In spite of numerous studies examining the
relationship between insight and severity of the mental disorder or insight and cog-
nitive impairment, it remains difficult to answer this basic question. As has already
been seen, complexities around the definition and assessment of insight are an
important factor in this. However, consequently, the relationship between insight
and other clinical variables, such as prognosis, severity of psychopathology, treat-
ment compliance, cognitive impairment, etc. remains unclear.
3.2.1 Insight and socio-demographic variables

Is the degree of insight held by an individual related to age, gender or education?
To what extent might social and cultural factors contribute to the manifestation
and indeed the elicitation of insight? Does the duration of mental illness, the age at
which it developed have any relationship with the level of insight shown? These
sorts of questions may be important to address when trying to explore the nature
and determinants of insight into mental disorders. Whilst numerous studies have
reported on the relationship between insight and socio-demographic variables, for
most, this has not been the primary focus or aim of the study. This makes it diffi-
cult to obtain meaningful answers on the basis of existing work for two main rea-
sons. Firstly, it means that most studies were not specifically designed to answer
such questions and hence different methodologies might be required in order to
do so. Secondly, as this issue has not been the primary aim of the study, it precludes
initial or preliminary theoretical exploration of the structure of insight and conse-
quent possible theoretical predictions concerning outcome. Any significant results
could only be examined in a post-hoc fashion and explanations limited by the
inherent biases of such methods. Bearing in mind these caveats, empirical studies
reporting on these associations can be divided into those showing no correlations
between insight and socio-demographic variables (Table 3.1), and those studies
Table 3.1 Studies reporting NO association between insight and socio-demographic variables
Study Patients* Insight assessment Result
Heinrichs et al. n 38 Patients dichotomised No differences between patients with

(1985) according to case-note and without insight in relation to age,
descriptions gender or socio-economic status
Greenfeld et al. n 21 Interview structured No correlation with demographic
(1989) along defined variables
dimensions
David et al. n 91 SAI No correlation with age or gender
(1992) PSE: insight item
Takai et al. n 57 PSE: insight item No correlations with socio-demographic
(1992) variables
McEvoy et al. n 26 ITAQ No correlation with age of onset,
(1993b) Clinical vignettes chronicity or illness activity
Young et al. n 31 SUMD: abridged No correlation with age, education and
(1993) chronicity
Amador et al. n 348 SUMD: abridged No correlation with age, gender and
(1994) education
Cuesta and n 40 AMDP: three items (LII) No correlation with age, gender and
Peralta (1994) education
Lysaker and n 92 PANSS: item G12 No correlation with age, gender, race,
Bell (1994) education, age at first hospitalisation,
length of longest full-time job
Peralta and n 115 SAI No correlation with age,
Cuesta (1994) AMDP: three items (LII) gender and education
Vaz et al. (1994) n 64 ITAQ No correlation with age of onset,
education
Ghaemi et al. n 28 ITAQ No correlation with socio-demographic
(1995) variables
Lysaker and n 44 PANSS: item G12 No correlation with age, years of
Bell (1995) education
Almeida et al. n 40 SAI No correlation with age, age of onset,
(1996) PSE: insight item duration of illness
Collins et al. n 58 SAI No correlation with gender
(1997)
Dickerson et al. n 87 PANSS: item G12 No correlation with age, gender, age of
(1997) onset, duration of illness, years of
education
Table 3.1 (cont.)
Lysaker et al. n 101 SUMD: abridged No differences between patients with and
(1998b) without insight in terms of their
backgrounds
Peralta and n 54 AMDP: three items (LII) No correlation between socio-
Cuesta (1998) demographic variables and insight at
admission, discharge or change in
insight
Schwartz n 64 PANSS: item G12 No correlation with age, total years of
(1998a) treatment
Larøi et al. n 21 SUMD No correlation with age, gender,
(2000) education and age at onset
Chen et al. n 80 SUMD: abridged No correlation with age, education,
(2001) illness duration
Schwartz (2001) n 223 SUMD No correlation with age, gender,
substance abuse
McCabe et al. n 89 SAI No correlation with socio-demographic
(2002) variables
Arduini et al. n 64 SUMD: abridged No correlation with age, gender, years of
(2003) education, duration of illness
* Diagnoses not specified here, since detailed in text and subsequent tables, but majority of patients diagnosed
with psychotic disorder, mainly schizophrenia, also schizoaffective, bipolar, affective and mixed psychoses.
Abbreviations: AMDP-LII: Lack of Insight Index from three items of the Manual for the Assessment and
Documentation of Psychopathology; ITAQ: Insight and Treatment Attitude Questionnaire; PANSS: Positive and
Negative Syndrome Scale; PSE: Present State Examination; SAI: Schedule for Assessing Insight; SUMD: Scale
to Assess Unawareness of Mental Disorder.
showing at least some correlation between insight and socio-demographic vari-

ables (Table 3.2).
As can be seen from the tables, the studies are fairly balanced in terms of their
sizes and the types of insight assessments used. Overall, many more studies report no
association between insight and socio-demographic variables though they range
on the numbers and types of socio-demographic variables included in the correla-
tions analysis.
In terms of the associations reported, there seems to be little consistency in the
results. Neither gender nor age appear to be significantly relevant factors, while the
Table 3.2 Studies reporting some correlation between insight and socio-demographic variables
Study Patients* Insight assessment Results
Linn (1965) n 593 Answers to questions about Increased duration of illness associated
what patients believed with reduced insight
was wrong with them
Soskis and n 32 Standardised questionnaire Women have more positive attitude
Bowers (1969) on attitudes to psychosis to psychosis than men
Appelbaum n 50 Standardised questionnaire: Men have greater insight than women.
et al. (1981) seven conceptual categories Younger age is associated with better
insight
Wciórka n 100 Structured questionnaire Patients with negative, isolating
(1988) on attitudes to illness attitudes had lower levels
of education
Caracci et al. n 20 Awareness of psychiatric Increased duration of illness associated
(1990) disorder dichotomised with reduced awareness of psychiatric
(present/absent). disorder and reduced awareness of
Awareness of involuntary movements
involuntary movements
(0–3 rating)
Taylor and n 30 1. Question whether they Poor insight associated with more
Perkins (1991) have mental health problem previous hospital admissions, female
2. Discrepancy between patients, older age
patients and staff on
Awareness of Disabilities
Scale
Amador et al. n 43 SUMD Age at first psychiatric evaluation
(1993) associated with insight (greater
retrospective awareness of achieved
effects of medication associated with
earlier age of psychiatric contact)
David et al. n 150 PSE item 104 Patients with better insight had parents
(1995) from socio-economic classes I and II
Kemp and n 29 SUMD: abbreviated Women showed increased insight
Lambert (1995) (attribution of past illness) over course
of hospital admission
Cuffel et al. n 89 Awareness of illness Women showed reduced awareness.
(1996) interview (recognition Use of illicit drugs associated
of mental illness and with increased awareness
need for psychiatric treatment)
Table 3.2 (cont.)
Fennig et al. n 189 Insight item from Being married was associated with
(1996) Hamilton Depression better insight. (No correlation with age,
Rating Scale gender, ethnicity, etc.)
Johnson and n 318 Assessments based on Caucasian British patients

Orrell (1996) case-note descriptions rated as having more insight than other
ethnic groups
MacPherson n 64 SAI Insight correlated with educational

et al. (1996) attainment
Kim et al. n 63 SAI Impaired insight associated with later

(1997) age of onset of illness
Lysaker et al. n 81 PANSS: item G12 Increased insight associated with earlier
(1998a) age of first hospitalisation
Sanz et al. n 33 ITAQ Non-illicit drug use associated with

(1998) SAI (and SAI-E) higher levels of insight.
IPQ (preliminary) Years of education correlated
PANSS: item G12 with insight (IPQ only)
Lysaker et al. n 74 PANSS: item G12 Patients with impaired insight were
(1999) significantly older
Marks et al. n 59 SAIQ Increased duration of illness associated

(2000) with impaired insight
Weiler et al. n 187 ITAQ No correlation with demographics

(2000) except for bipolar patients in whom age
at first admission associated with
insight
White et al. n 150 SAI Ethnicity not associated with insight

(2000) but being born outside the UK
associated with reduced insight.
Insight not associated with education,
strength of religious beliefs, social class,
illicit drug use
Goldberg et al. n 211 PANSS: item G12 Association between insight and race:
(2001) white patients rated greater insight than
black patients.
Association between current substance
abuse and insight
Table 3.2 (cont.)
Pyne et al. n 177 Dichotomised according to Duration of illness and younger age
(2001) answer whether patients correlated with reduced insight in
believed they had a outpatients.
mental illness.
Abbreviations: IPQ: Insight in Psychosis Questionnaire; ITAQ: Insight and Treatment Attitude Questionnaire;
PANSS: Positive and Negative Syndrome Scale; PSE: Present State Examination; SAI: Schedule for Assessing
Insight; SAI-E: Schedule for Assessing Insight – Expanded version; SAIQ: Self-Appraisal of Illness Questionnaire;
SUMD: Scale to Assess Unawareness of Mental Disorder.
few studies that find associations, yield conflicting results (Table 3.2). Age at first
admission to hospital was found in four studies to be related to insight (Kim et al.,
1997; Lysaker et al., 1998a; Weiler et al., 2000) or an aspect of insight (Amador et al.,
1993) with increased insight being associated with earlier age of hospital admission.
Interestingly, in a larger study using the abbreviated version of the SUMD (which did
not include ratings of retrospective awareness), this latter finding was not replicated
(Amador et al., 1994). Duration of illness was also found to be associated with insight
in three studies with increasing length of illness correlating with poorer insight (Linn,
1965; Caracci et al., 1990; Marks et al., 2000). Pyne et al. (2001), on the other hand,
only found an association between duration of illness and insight in their outpatients
as opposed to their inpatients. Furthermore, their reported association was in the
opposite direction from the previous studies in that patients with shorter duration of
illness seemed to show poorer insight. Owing to the methodological issues raised earl-
ier, it is difficult to draw very much from these results and there may be effects from
various confounding factors, e.g. as severity of illness itself. A few studies reported
a significant correlation between insight and education (MacPherson et al., 1996;
Rossell et al., 2003) whilst Sanz et al. (1998), in their study comparing the use of sev-
eral insight measures, found that insight was related to education only when insight
was assessed with the IPQ instrument. The study by David et al. (1995), appears to be
the sole to report a positive association between insight and higher social class.
Of interest are the studies that have started to explore the relationship between
insight and ethnicity. Conducting a case-note study with the specific aim of exam-
ining the relationship between ethnicity and patients’ insight, Johnson and Orrell
(1996) found that white British patients were rated as having significantly more
insight than other ethnic groups. Though, as the authors point out, the design of
the study did not permit administration of standardised or detailed assessments of
insight, nor could consideration be taken of interacting variables such as severity

of psychopathology. Two further prospective studies found similar results: the
study by White et al. (2000) did not find a specific relationship between insight and
ethnicity but showed that being born outside the UK was associated with reduced
insight. Goldberg et al. (2001) found that white patients were rated as having
greater insight than black patients. On the other hand, Fennig et al. (1996) found
no association between insight in patients presenting with first admission for psych-
osis and ethnicity. The question thus remains as to the nature of such differences
between insight in different cultures, and to what extent they might reflect true dif-
ferences in insight and to what extent socio-cultural biases are contributing. Whilst
not directly assessing insight, Townsend (1975), in a study designed to explore cul-
tural differences in concepts of mental illness, examined the attitudes of German
psychiatric inpatients (n 112) and American psychiatric inpatients (n 110).
He found significant differences in the way that mental disorders were conceived.
The German patient group had a more biological/organic view of mental disorders
on which they had little individual control. On the other hand, the American
patient group had a more behavioural perspective towards mental illness in
regards to which they felt they were able to exert some control. Differences in the
ways in which mental disorders are conceived in general are likely to contribute to
the views and understanding individuals will develop when affected.
3.2.2 Insight and past psychiatric illness

Does insight increase with experience of more episodes of illness? Do patients who
have had more hospital admissions develop more insight into their illness and how
this affects them? Or, are frequent hospital admissions an indicator of more severe
illness and have little direct relationship with patients’ insight? Once again, most
studies have not been designed to answer those questions although many report on
the correlation between insight and numbers of past hospital admissions (Table 3.3).
It is evident that most studies report no relationship between levels of insight and
the numbers of previous hospital admissions. In the studies that do report some
association, then it is generally in the direction of increased insight being associated
with increased hospital admissions (Takai et al., 1992; Amador et al., 1993; Peralta &
Cuesta, 1994; Ghaemi et al., 1996). However, some authors also report the opposite
finding with poor insight associated with more hospital admissions (Taylor &
Perkins, 1991; Moore et al., 1999). A more complicated relationship is described by
Lysaker et al. (2003) who found that poor insight was associated with more hospital
admissions only in patients with poor cognition (on the Wisconsin Card Sorting Test
(WCST)) but not in patients with average cognitive function. Given the methodo-
logical issues involved, it is not really possible to interpret such results at this stage
though various questions may be raised in the light of these findings. For example,
Table 3.3 Studies reporting on associations between insight and previous hospital admissions
Appelbaum n 50 Standardised No correlation with numbers of past

et al. (1981) questionnaire: seven admissions
conceptual categories
Heinrichs n 38 Patients dichotomised No correlation with numbers of past

et al. (1985) according to case-note admissions
descriptions
Greenfeld n 21 Interview structured More previous hospital admissions associated

et al. (1989) along defined with less insight (along one dimension)
dimensions
McEvoy n 52 ITAQ No correlation with numbers of past

et al. (1989b) admissions
Taylor and n 30 1. Question whether More previous hospital admissions associated

Perkins (1991) have mental health with less insight
problem
2. Discrepancy between
patients and staff on
Awareness of
Disabilities Scale
David et al. n 91 SAI No correlation with numbers of past

(1992) PSE: insight item admissions
Takai et al. n 57 PSE: insight item More previous hospital admissions associated
(1992) with increased insight
Amador et al. n 43 SUMD Moderate correlation between numbers of

(1993) past hospital admissions and aspects of
insight
McEvoy et al. n 26 ITAQ No correlation with numbers of past

(1993b) Clinical vignettes admissions
Young et al. n 31 SUMD: abridged No correlation with numbers of past

(1993) admissions
Amador et al. n 348 SUMD: abridged No correlation with numbers of past

(1994) admissions
Lysaker and n 92 PANSS: item G12 No correlation with numbers of past

Bell (1994) admissions
Peralta and n 115 SAI More past hospital admissions associated

Cuesta (1994) AMDP: three items (LII) with increased insight
Table 3.3 (cont.)
Ghaemi et al. n 28 ITAQ No correlation with numbers of past

(1995) admissions
Lysaker and n 44 PANSS: item G12 No correlation between numbers of past

Bell (1995) admissions and changes in insight
Ghaemi et al. n 16 ITAQ More past hospital admissions associated with

(1996) increased insight
Dickerson n 87 PANSS: item G12 No correlation with numbers of past

et al. (1997) admissions
Lysaker et al. n 81 PANSS: item G12 No correlation with numbers of past

(1998a) admissions
Lysaker et al. n 101 SUMD: abridged No correlation with numbers of past

(1998b) admissions
Sanz et al. n 33 ITAQ Correlation between numbers of past

(1998) SAI (and SAI-E) admissions and insight only
IPQ (preliminary) significant with IPQ
PANSS: item G12
Moore et al. n 46 SUMD Poor insight correlated with more past

(1999) admissions
Larøi et al. n 21 SUMD No correlation with numbers of past

(2000) admissions
White et al. n 150 SAI Weak association between increasing insight

(2000) and increased numbers of past admissions
Goldberg n 211 PANSS: item G12 No correlation with numbers of past

et al. (2001) admissions
Pyne et al. n 177 Dichotomised Inpatients: reduced insight associated with

(2001) according to answer increased numbers of past admissions.
whether patients Outpatients: reduced insight associated
believed they had a with reduced numbers of past admissions
mental illness
Abbreviations: IPQ: Insight in Psychosis Questionnaire; ITAQ: Insight and Treatment Attitude Questionnaire;
PANSS: Positive and Negative Syndrome Scale; PSE: Present State Examination; SAI: Schedule for Assessing
Insight; SAI-E: Schedule for Assessing Insight – Expanded version; SUMD: Scale to Assess Unawareness of
Mental Disorder.
do patients who show greater insight perhaps seek medical help more frequently and
are more willing to accept hospital admissions? Some indirect support could be
given to this view by the results of studies showing that informal patients show
greater insight than patients admitted involuntarily (McEvoy et al., 1989c; David
et al., 1992; Ghaemi et al., 1995; Upthegrove et al., 2002). On the other hand, the study
by Pyne et al. (2001) suggests a more complicated association between patients’
insight and hospital admissions showing that a significant relationship was only evi-
dent in outpatients whereas inpatients at the time of the study showed the opposite
association. Results also point to the possibility that perhaps some aspects of insight
might be more relevant in the association between hospital admissions than others
(Greenfeld et al., 1989; Amador et al., 1993; Sanz et al., 1998). An interesting recent
study explored the question in a different way by comparing insight (SUMD) in first
episode psychosis patients (n 144) with insight in multiple episode psychosis
patients (n 312) (Thompson et al., 2001). They found that a significantly greater
proportion of multiple episode psychotic patients were aware of having a mental dis-
order and were aware of the effects of medication than first episode psychosis
patients. The researchers thus suggested that over time patients might show
increased insight into their illness as they learn from their experiences, become less
defensive and become adept at using medical terms. They did caution, however, that
using medical terms may not necessarily reflect true insight. The question of the con-
tribution made by past experience towards the attainment of insight therefore
remains to be answered. Empirical work in this field is additionally difficult because
of the problems involved in trying to control for the multitude of variables likely
to be important in the development of insight.
3.2.3 Insight and prognosis

Is it important for patients to have good insight? Does having good insight into one’s
illness relate to a better or worse prognosis? Or, is insight perhaps independent of the
condition itself and related more to individual and/or socio-cultural factors? Again
these are the sorts of questions that need to be asked in order to determine more
clearly the nature of insight as a clinical phenomenon, and its significance and rela-
tionship with clinical and other factors. There have been few studies specifically
reporting on the association between insight and prognosis and, in particular, fewer
prospective studies. One of the additional difficulties in exploring insight in regards
to this area relates to the assessment of prognosis itself, i.e., how can this be best evalu-
ated? For example, some studies use the number of subsequent re-hospitalisations
over a time period as an indicator whilst others use duration of an index admission
or response to medication, etc. Clearly, however, these variables are assessing quite
different things in relation to the patient’s prognosis (e.g. short term versus long
term, hospitalisation versus response to management, etc.), which complicates
things further when it comes to making comparisons between studies (Table 3.4).
Table 3.4 Studies reporting on association between insight and clinical outcome
Study Patients* Insight assessment Clinical outcome Results
Eskey (1958) n 300 Categorised on Duration of No correlation between

basis of mental hospital insight and length of
state examination admission admission
(insight, partial
insight, no insight)
Kahn and n 63 Denial Personality Response to ECT Explicit verbal denial
Fink (1959) Score dichotomised associated with better response
to high- and to ECT
low-denial groupings
Hankoff n 169 Denial of illness Response to Denial associated with better
et al. (1960a) questionnaire medication. response to medication but
(rating 1–4) Hospitalisation more hospitalisation
rate over
6 months
Hankoff n 103 Denial of illness Psychiatric Denial associated with better
et al. (1960b) questionnaire progress notes prognosis when treated with
(rating 1–4) placebo
Linn (1965) n 593 Answers to questions Duration of No evidence that insight
about what patients hospital predicted better prognosis
believed was wrong admission
with them
Small et al. n 68 Structured Numbers of Positive change in attitudes
(1965) questionnaire on re-hospitalisation associated with better
attitudes about and/or transfers to prognosis
treatment and chronic care
hospitalisation institutions over
16–20 months
Soskis and n 32 Standardised Numbers of No correlation between
Bowers (1969) questionnaire on re-hospitalisation. attitudes and
attitudes to Post hospital re-hospitalisation rates.
psychosis adjustment scales Positive attitudes correlated
(3–7 years (KAS 1 and 2), BFR with higher levels of
post-discharge) post hospital adjustment
Exner and n 148 Discrepancy Relapse: needing Greater discrepancy
Murillo (1975) between patients and re-hospitalisation (poorer insight)
relatives ratings on within 12-month predicted relapse
Katz Adjustment post-discharge
Scale
Table 3.4 (cont.)
Roback and n 24 Tolor–Reznikoff Hospital Increased insight associated

Abramowitz Test (clinical Adjustment Scale with better hospital
(1979) vignettes) adjustment but more distress
Symptom checklist
McGlashan n 30 Soskis and Quantity and Less negative attitudes

and Carpenter Bowers attitude quality of work associated with better
(1981) scales and social outcome
relations, absence
of symptoms,
fullness of life
Heinrichs n 38 Patients Resolution of Increased insight predicted

et al. (1985) dichotomised psychotic relapse. successful resolution of
(insight versus Retrospective relapse on outpatient basis.
no insight) study Reduced insight
according to associated with
case-note more hospitalisation
descriptions
Lelliott n 49 Structured interview Medication and No difference in outcome

et al. (1988) OCD on attitudes behaviour therapy between patients with
to symptoms poor and good insight
McEvoy n 52 ITAQ Rates of Good insight associated with

et al. (1989a) re-hospitalisation less re-hospitalisation
over 30–40
months since
discharge
Greenfeld n 30 Schedule for Body mass index Good insight associated

et al. (1991) Anorexia assessment of changes during with positive outcome
nervosa insight into hospitalisation measures
(DSM-IIIR) illness
Taylor and n 30 1. Question whether Functioning level. Denial associated

Perkins (1991) have mental Subjective with longer contact
health problem well-being with services
2. Discrepancy Compliance with but less distress
between patients services
and staff on
Awareness of
Disabilities Scale
Table 3.4 (cont.)
Amador n 43 SUMD Duration of Modest correlation

et al. (1993) hospital between insight
admission and length of
admission
Foa et al. n 20 Structured Response to Poor insight associated
(1999) OCD interview on behaviour with worse outcome
fixity of beliefs therapy (see text, section 3.2.9)
Eisen et al. n 71 BABS Response to Degree of insight
(2001) OCD sertraline did not predict response to
(DSM-IV) treatment sertraline
(open label study)
*Diagnoses not specified here, since detailed in text and subsequent tables, but majority of patients diagnosed
Exceptions are indicated.
Abbreviations: BABS: Brown Assessment of Beliefs Scale; BFR: Brief Follow-up Rating; ITAQ: Insight and
Treatment Attitude Questionnaire; KAS: Katz Adjustment Scale; OCD: Obsessive-Compulsive Disorder;
SUMD: Scale to Assess Unawareness of Mental Disorder.
It can be seen that results of studies are varied. Slightly more studies appear to sug-
gest that better insight is associated with improved clinical outcome (Small et al.,
1965; Exner & Murillo, 1975; McGlashan & Carpenter, 1981; Heinrichs et al., 1985;
McEvoy et al., 1989a; Greenfeld et al., 1991; Amador et al., 1993). A few studies report
no association with prognosis (Eskey, 1958; Linn, 1965; Eisen et al., 2001) and some
suggest that insight is associated with worse clinical outcome (Kahn & Fink, 1959;
Hankoff et al., 1960b). Yet others indicate more mixed results with insight relating to
some aspects of good but also to some aspects of worse outcome (Hankoff et al.,
1960a; Roback & Abramowitz, 1979; Taylor & Perkins, 1991). However, given the
particular variability between the studies not only in how insight is assessed but also
in the different clinical outcome indicators and different patient groups, the rela-
tionship between insight and prognosis cannot yet be determined.
3.2.4 Insight and severity of psychopathology

Perhaps most empirical studies exploring insight have focused on the relationship
between patients’ insight into their illness and the severity of their mental disorder.
Does insight deteriorate with increasing severity of illness? Immediately, however,
this raises further complications in terms of addressing the meaning of severity of
mental illness, for, how is that best assessed? Will insight relate more to the degree
of psychopathology in terms of numbers of concomitant symptoms, or perhaps to

the types or patterns of symptoms/syndromes experienced? Or, is severity better
determined by levels of functional ability? Studies in this area again yield very vari-
able results (Table 3.5).
The variability in the results is of different types. Firstly, a number of studies
show no association at all between the degree of patients’ insight into mental dis-
order and the severity of their mental disorder (e.g. McGlashan & Carpenter, 1981;
McEvoy et al., 1993a, b; Cuesta & Peralta, 1994; Lysaker & Bell, 1994; David et al.,
1995; Lysaker & Bell, 1995; McEvoy et al., 1996; Flashman et al., 2000; Eisen et al.,
2001). Secondly, a number of studies report a direct relationship between poor
insight and global severity of mental disorder, i.e. the poorer the patient’s insight,
the more severe his/her mental illness (e.g. David et al., 1992; Takai et al., 1992;
Young et al., 1993; Kemp & Lambert, 1995; Fennig et al. 1996; Young et al., 1998;
Rossell et al., 2003; Eisen et al., 2004). Thirdly, another group of studies find that
whilst there is no (or little) direct association between insight and global severity of
illness, there is an association between ‘positive’ symptoms/syndromes (Almeida
et al., 1996; Collins et al., 1997; Kim et al., 1997; Lysaker et al., 1998; Schwartz 1998a, b;
Carroll et al., 1999). On the other hand, other studies disagree with the associ-
ation with positive syndromes and instead report on an association between poor
insight and more severe ‘negative’ symptoms/syndromes (McPherson et al., 1996;
Cuesta et al., 2000; Larøi et al., 2000; McCabe et al., 2002). Other studies report an
association between poor insight and severity of both positive and negative symptoms
(Keshavan et al., 2004; Mintz et al., 2004). Fourth, some studies find rather that poor
insight is associated with specific symptoms or groups of symptoms (Heinrichs et al.,
1985; Lysaker et al., 1994; Vaz et al., 1994; Dickerson et al., 1997; Debowska et al.,
1998; Baier et al., 2000). And in these latter studies, the symptoms, that elicit the
association, themselves differ, e.g. ‘severity of grandiosity’ correlated with poor
insight in the study by Heinrichs et al. (1985) and ‘formal thought disorder’ correlated
with poor insight in the Baier et al. (2000) investigation. Then there are studies,
which report association between only some dimensions of insight with different
aspects of illness severity (Amador et al., 1993; Amador et al., 1994; Vaz et al., 1994;
Buckley et al., 2001; Yen et al., 2003; Sevy et al., 2004). For example, the study by Sevy
et al. (2004) in 96 patients with schizophrenia reported an association between poor
awareness of current symptoms and all factors of severity derived from the PANSS.
However, the lack of awareness of having a mental illness and its social conse-
quences was correlated only with the positive factor from PANSS. Similarly, the lack
of awareness of achieved effects of medication correlated only with the autistic pre-
occupation factor from the PANSS and no correlations at all were obtained between
misattribution of symptoms and any of the PANSS factors. The authors conclude
that different components of insight are related in different ways to the various
Table 3.5 Studies reporting on association between insight and severity of psychopathology
Patients Insight Psychopathology

Study (diagnostic classification) assessment assessment Results
McGlashan n 30 Soskis and Global No correlation

and Carpenter Schiz. (DSM-II) Bowers psychopathology between attitudes
(1981) inpatients attitude ratings to psychosis
and follow-up scales and severity
Heinrichs n 38 Patients BPRS No relationship

et al. (1985) Chronic schiz. dichotomised: between insight and
Retrospective with and severity. Poor I
case-note study without insight associated with more
severe grandiosity score
McEvoy n 52 ITAQ BPRS No consistent

et al. (1989b) Schizophrenia CGI relationship
(DSM-III) between insight
inpatients and severity
David n 91 SAI PSE total score Less I associated with

et al. (1992) Mixed psychotic PSE: insight more severe
(PSE) item psychopathology
Mainly inpatients (SAI measure only)
Marková n 43 IPQ BPRS Poor I associated with

and Berrios Schizophrenia, (preliminary). HDRS greater severity at
(1992b) depression. Semi-structured admission (BPRS) and
(DSM-IIIR), interview more depression at d/s
inpatients,
admission and
discharge
Takai et al. n 57 PSE: insight BPRS Less I associated with

(1992) Schizophrenia item.Subjective 4-positive greater BPRS scores.
(DSM-IIIR). ratings (FBS). symptoms Less I associated with
Ratios of FBS (SADS). increased scores on
and BPRS. 5-negative both positive and
symptoms negative symptom
(SANS). scores (SADS, SANS)
Amador n 43 SUMD SAPS No relationship

et al. (1993) Schiz./schizaff. Insight item SANS between I and severity,
(DSM-IIIR), from HDRS. HDRS except:
inpatients – current awareness and
reduced total SAPS
Table 3.5 (cont.)

– retrospective
awareness and
reduced depression
McEvoy n 25 ITAQ: BPRS No correlation

et al. (1993a) Schiz./schizaff. modified CGI between I
(DSM-III), and severity
outpatients
McEvoy n 26 ITAQ Global No correlation between

et al. (1993b) Schiz./schizaff. Clinical Assessment I and severity
(DSM-III), inpatients vignettes Scale
Young et al. n 31 SUMD Likert scales of Poor I associated with

(1993) Chronic schiz. severity for each increased severity of
(DSM-IIIR), in and symptom symptoms
outpatients
Amador n 348 SUMD: SAPS Some correlation

et al. (1994) Mixed psychotic, abridged SANS between low I and
affective higher SAPS.
(DSM-IIIR), General level of
inpatients awareness
unrelated to symptom
severity except
delusions, thought
disorder, social isolation
Cuesta and n 40 AMDP: SAPS No correlation between

Peralta Schiz. three items SANS I and severity
(1994) (DSM-IIIR) (LII)
inpatients
Lysaker and n 92 PANSS: item PANSS No correlation between

Bell (1994) Schiz./schizaff. G12 I and severity (global,
(DSM-IIIR) positive and negative)
Lysaker n 85 PANSS: item PANSS No correlation between

et al. (1994) Schiz./schizaff. G12 I and severity (global,
(DSM-IIIR) positive and negative).
Poor I associated with
some items: poor
rapport, conceptual
Table 3.5 (cont.)

disorganisation,
stereotyped thinking,
suspiciousness, etc
Michalakeas n 77 females ITAQ BPRS Schiz. patients – no

et al. (1994) Schiz., mania, depression correlation between I
(DSM-IIIR), inpatients, and BPRS. More I
admission and discharge correlated with less
severity at discharge.
Manic patients: poor
insight correlated with
severity at admission
and discharge
Depression Patients:
no correlation between
I and severity at
any time
Peralta and n 115 AMDP: SAPS Poor I associated with

Cuesta Schiz. three items. SANS fewer depressive
(1994) (DSM-IIIR) inpatients SAI symptoms
Vaz et al. n 64, males ITAQ: 2 PANSS No correlation between

(1994) Acute Schiz. factors: F1: total I or F1 and global
(DSM-IIIR) awareness of severity
Inpatients illness. F2: Correlation between F2
awareness and global severity.
of need Correlation between
for Rx F1: somatic
preoccupation, poor
rapport; F2: hostility,
poor rapport
David n 150 PSE: item 104 PSE total score No correlation between
et al. (1995) Mixed psychoses I and global severity
(DSM-IIIR), inpatients,
follow-up
Ghaemi n 28 ITAQ BPRS No correlation between

et al. (1995) Acute mania CGI I and global severity
(DSM-IIIR) inpatients
Table 3.5 (cont.)

Lysaker n 44 PANSS: PANSS No correlation between

and Bell Schiz./schizaff. item G12 I and severity (global
(1995) (DSM-IIIR), positive and negative)
rehabilitation
Kemp and n 29 SUMD: PANSS Poor I associated with
Lambert Schiz. (DSM-IIIR) modified greater severity (positive,
(1995) Inpatients and negative and total)
(T1 and T2) and grandiosity and
less depression
Almeida n 40 SAI PSE No correlation with
et al. (1996) Late paraphrenia PSE: item 104 BPRS negative symptoms.
(ICD-9) In- and out SAPS Poor I associated with
and day patients HEN worse BPRS and more
positive symptoms
Fennig n 189 Insight item SAPS Poor I associated with
et al. (1996) Schiz., Bipolar, from Hamilton SANS severity at baseline.
psychotic depression, Depression Severity not predictive
other psychoses Rating Scale of I at 6-month
follow-up
MacPherson n 64 SAI PANSS No correlation between
et al. (1996) Schiz. (DSM-IIIR) I and positive
syndrome score but
correlation between
poor I and more severe
negative syndrome score
McEvoy n 32 ITAQ BPRS No correlation between
et al. (1996) Schiz. (DSM-IIIR) I and severity
Collins n 58 SAI PANSS Strongest association
et al. (1997) Schiz. (DSM-IIIR) Calgary between poor I and
outpatients Depression positive symptoms
Scale score
Small correlation
between poor I and
negative symptoms
score
worse depression
Table 3.5 (cont.)

Dickerson n 87 PANSS: item PANSS Poor I associated with

et al. (1997) Schiz./schizaff. G12 severity of symptoms,
(DSM-IIIR), particularly delusions,
outpatients paranoia, different
abstract thinking, poor
rapport, etc
More I related to more
severe anxiety
Ghaemi n 30 SUMD HDRS Better I associated
et al. (1997) Seasonal affective modified for CGI with more severe
disorders (DSM-IIIR) mood depression
Kim et al. n 63 SAI BPRS Poor I associated with
(1997) Schiz. (ICD-10) SANS more severe positive
Inpatients and HDRS symptoms
outpatients No correlation with
negative symptoms
Cuesta n 100 PANSS: item PANSS Poor I associated with
et al. (1998) Acute schiz. G12, AMDP: more severe symptoms
(DSM-IIIR), three items in disorganised and
inpatients excited dimensions and
with more severe
negative symptoms
Debowska n 61 PANSS: PANSS Poor I associated with
et al. (1998) Paranoid schiz. item G12 Inventory of more severe delusions
(DSM-IIIR), four items re delusion and hostility
inpatients Rx attitude contents (positive scale) and
with more severe
negative symptoms
Lysaker n 81 PANSS: item PANSS Poor I associated with
et al. (1998a) Schiz./schizaff. G12 more severe positive
(DSM-IIIR) symptoms
No correlation with
negative symptoms
Lysaker n 101 SUMD: PANSS Poor I associated with
et al. (1998b) Schiz./schizaff. abridged Schedule for more severe positive
(DSM-IIIR) deficit symptoms
syndrome No correlation with
negative symptoms
Table 3.5 (cont.)

Sanz n 33 ITAQ PANSS Correlations varied

et al. (1998) Mixed psychotic SAI (and BPRS: according to I rating
disorders SAI-E) expanded used. SAI and PANSS
(DSM-IV), IPQ BDI correlated with total
mainly inpatients (preliminary) CGI severity. All measures
PANSS: item correlated with
G12 grandiosity item.
SAI, ITAQ, PANSS
ratings of I correlated
with depression severity
Schwartz n 64 PANSS: item PANSS Poor I associated with

(1998a) Schiz. G12 more severe positive
(DSM-IV) symptoms
No correlation with
negative or general
symptoms
Schwartz n 66 SUMD PANSS Poor I associated with

(1998b) Schiz. more severe positive
(DSM-IV) symptoms
outpatients No correlation with
negative or general
symptoms
Smith n 33 SUMD BPRS No correlation with

et al. (1998) Schiz./schizaff. SAPS severity except: good I
(DSM-IV), in and SANS associated with more
outpatients depression and less
disorganised symptoms
Young n 129 SUMD BPRS Poor I associated with

et al. (1998) Schiz., bipolar greater global severity
(DSM-IIIR), in
and outpatients
Carroll n 100 ITAQ PANSS Poor I associated with

et al. (1999) Schiz. (DSM-IIIR) MADRS more severe positive
Inpatients prior symptoms and less
to discharge depressed mood.
Improvement in I
Table 3.5 (cont.)

related to worsening mood

but not to improvement in
positive symptoms
Lysaker n 74 PANSS: PANSS Poor I associated with

et al. (1999) Schiz./schizaff. item G12 more severe positive
(DSM-IIIR), inpatients symptoms at admission
and following and after 5 months.
rehabilitation No correlation between
I and symptoms after
1 year
Baier n 37
et al. (2000) Schiz./schizoaff. IS SAPS No correlation with
Inpatients and Davidhizar SANS severity except: poor I
outpatients et al. (self- associated with more
rating insight formal thought disorder
scale)
Caracci n 78 Questions Rockland Poor I associated with

et al. (1990) Chronic schiz. on awareness Tardive more severe
(DSM-IIIR), of mental Dyskinesia orofacio-lingual
outpatients disorder Scale dyskinesia
(insight
present or
absent)
Cuesta n 75 SUMD CASH: positive Poor I-SUMD/AMDP

et al. (2000) Schiz., affective and ITAQ and negative associated with worse
schizaff. disorders AMDP: three syndrome scores negative symptoms.
(DSM-IV), index, items No correlation with
follow-up affective dimension
Flashman n 30 SUMD BPRS No correlation

et al. (2000) Schiz., schizaff., SAPS between I and severity
(DSM-IV) SANS
Larøi et al. n 21 SUMD BPRS No correlation between

(2000) Schiz. (DSM-IV) I and severity except
for association between
poor I and anergia
category
Table 3.5 (cont.)

Smith T.E. n 46 SUMD: SANS Poor I associated with

et al. (2000) Schiz./schizaff. abridged SAPS more formal thought
(DSM-IV), BPRS disorder and worse
outpatients depression and better
positive symptoms.
*No correlation with
negative symptoms
Weiler n 187 ITAQ BPRS Improvement in I

et al. (2000) Mixed psychoses, associated with
affective disorders improvement in
(DSM-IIIR), severity of symptoms
inpatients,
admission, d/s
White et al. n 150 SAI PANSS Poor I associated with

(2000) Schiz. (DSM-IV, Calgary greater severity of
ICD-10), in and Depression psychotic symptoms.
outpatients Scale No correlation with
depression but poor I
associated with more
depression when
psychotic symptoms
partialled out
Buckley n 50 SUMD BPRS No correlation between

et al. (2001) Schiz./schizaff. severity and awareness
(DSM-IV) inpatients of illness/effects of Rx.
Some correlations
between I and positive
and negative syndromes.
more depression
Cassidy n 53 ITAQ SMS Poor I weakly related

et al. (2001) Bipolar (mania PANSS: to greater severity.
and mixed) G items Strong correlation with
(DSM-IV) delusions and
disorganisation. Better I
depression
Table 3.5 (cont.)

Chen et al. n 80 SUMD: BPRS No correlation with

(2001) Mixed psychoses abridged total severity.
and affective Improvement in I
disorders (DSM-IV), scores related to
inpatients, admission positive symptoms
and d/s scores
Eisen n 71 BABS Y-BOCS No correlation between

et al. (2001) OCD (DSM-IIIR) I and severity of OCD
Francis and n 29 ITAQ BPRS Poor I associated with

Penn (2001) Schiz., bipolar and PANSS: total severity, anergia
schizaff. disorders item G12 and thought disorder.
(DSM-IV), outpatients IS No correlation with
affective/disorganised
syndromes
Goldberg n 211 PANSS: PANSS Poor I associated with

et al. (2001) Schiz., bipolar, other item G12 more positive and
psychotic and negative symptoms.
affective (DSM-IV), No correlation with
in/outpatients general (G items)
Pyne n 177 Insight: Modified Good insight associated

et al. (2001) Schiz. present or Symptom with worse depression
Inpatients and absent on Checklist-90
outpatients response to
question if
think that
mentally ill
Schwartz n 223 SUMD SCI-FARS Poor I associated with

(2001) Schiz. (DSM-IV) more severe depressive
Outpatients symptoms
McCabe n 89 SAI SANS Poor I associated with

et al. (2002) Chronic schiz. SAPS more avolition-apathy
(DSM-IIIR), (SANS). Subscales of
outpatients I correlated with some
symptoms but majority
of I variance not
Table 3.5 (cont.)

explained by symptom
severity
Vaz et al. n 82 SAI PANSS Poor I associated with

(2002) Schiz. (DSM-IV) more severe
Outpatients psychopathology
Rossell n 78 males SAI-E SANS Poor I associated with

et al. (2003) Schizophrenia (DSM-IV) SAPS more severe
psychopathology,
particularly: delusions,
formal thought
disorder and
inappropriate affect
Yen n 33 SAI Young’s Mania No association between

et al. (2003) Bipolar: SAI-E Rating Scale I (SAI) and severity
currently manic (YMRS) of mania
(DSM-IV) Poor I on SAI-E
severe mania
Drake n 257 IS (Birchwood) PANSS: Insight not strongly

et al. (2004) 1st episode PANSS: delusions associated with
psychoses item G12 Delusion Scale: paranoia
(Schizophrenia PSYRATS Insight at admission
spectrum, DSM-IV) PANSS: anxiety, strongly associated
f/u 72% at depression, with (predicted)
18 months guilty and depression but
avolition items only weak at follow-up
Keshavan n 535 PANSS: PANSS: Poor I associated with

et al. (2004) 1st episode item G12 CGI positive, negative and
psychoses general psychopathology
(Schizophrenia (especially thought
spectrum, DSM-IV) disorder)
Eisen n 64 OCD (DSM-IV) BABS Y-BOCS Poor I associated

et al. (2004) n 85 BDD (DSM-IV) BDD-YBOCS with more severe
symptoms only in
BDD (not OCD)
Table 3.5 (cont.)

Mintz n 253 PANSS: PANSS Poor I associated with

et al. (2004) 1st episode psychoses item G12. Calgary higher levels of positive
(Schizophrenia Patients high Depression and negative symptoms
spectrum, DSM-IV). insight or low Scale at baseline and
f/u: 180 at 12 months insight f/u assessments
Sevy n 96 SUMD: PANSS: Different components

et al. (2004) Schizophrenia revised analysed of I correlated with
(DSM-IV) in relation to different PANSS factors
five factors (see text)
Documentation of Psychopathology; BABS: Brown Assessment of Belief Scale; BDD: Body Dysmorphic
Disorder; BDD-Y-BOCS: Yale-Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder;
BDI: Beck Depression Inventory; BPRS: Brief Psychiatric Rating Scale; CASH: Comprehensive Assessment
Schedule History; CGI: Clinical Global Impressions global severity item; HDRS: Hamilton Depression Rating
Scale; HEN: High Royds Evaluation of Negativity Scale; I: Insight; IPQ: Insight in Psychosis Questionnaire; IS:
Insight Scale; ITAQ: Insight and Treatment Attitude Questionnaire; MADRS: Montgomery and Asberg
Depression Rating Scale; OCD: Obsessive Compulsive Disorder; PANSS: Positive and Negative Syndrome Scale;
PSE: Present State Examination; PSYRATS: Psychotic Symptom Rating Scales; Rx: Treatment; SADS: Schedule
for Affective Disorders; SAI: Schedule for Assessing Insight; SAI-E: Schedule for Assessing Insight – Expanded
version; SANS: Scale for the Assessment of Negative Symptoms; SAPS: Scale for the Assessment of Positive
Symptoms; Schiz.: Schizophrenia; Schizaff.: Schizoaffective disorder; SCI-FARS: Structured Clinical Interview
for the Functional Assessment Rating Scale; SMS: Scale for Manic States; SUMD: Scale to Assess Unawareness
of Mental Disorder; Y-BOCS: Yale-Brown Obsessive Compulsive Scale; YMRS: Young’s Mania Rating Scale.
aspects of the patient’s illness (Sevy et al., 2004). Reporting on an opposite direction
of association between insight and severity of illness, one study examining insight
in patients with anorexia nervosa found that good insight related to more severe ill-
ness as assessed by duration of hospitalisation and degree of emaciation (Greenfeld
et al., 1991). Finally, some studies using several insight assessment measures at the
same time report on different associations between insight and severity of illness
with the different measures used (Sanz et al., 1998; Cuesta et al., 2000).
In the light of the variable outcomes of these empirical studies, it is clear that the
relationship between insight and severity of illness is not yet possible to define
definitively. The finding that some studies have reported improvements in patients’
insight over time, which seem to be independent of improvements in psy-
chopathology over the same time (McEvoy et al., 1989b; Jørgensen, 1995; Fennig
et al., 1996; Cuesta et al., 2000), further complicates the overall picture. In addition,
the studies summarised in Table 3.5 vary considerably in methodological design

which creates problems in making comparisons and obtaining consistent results.
Thus, studies range in size (n 21–348), diagnostic heterogeneity (some studies
include only patients with schizophrenia, others have a range of psychotic dis-
orders, some include patients with affective disorders with or without psychosis,
some are acute, others chronic, some are inpatients and others outpatients, etc.),
methods of insight assessment and measures of outcome. At the most, all that can
be said at present concerning the relationship between patients’ insight and sever-
ity of mental illness is that it is likely to be complicated. Many factors will play a
part in the complications, not just the difficulties around defining and assessing
insight, but also the problems of defining severity of mental illness and the need to
consider a great many different factors that are likely to be contributing to an indi-
vidual mental state.
3.2.5 Insight and cognitive function

Over the last decade particular interest has focused on examining the relationship
between insight and cognitive function or impairment. Much of this interest has
arisen as a result of, firstly, the findings that various cognitive deficits occur com-
monly in patients with severe mental illness, particularly schizophrenia (David &
Cutting, 1994; McKenna, 1994). And secondly, analogies have been made between
loss of awareness or anosognosia in patients with neurological conditions (see
Chapter 4) with loss of insight in patients with mental disorders (Amador et al.,
1991; Young et al., 1993; Mullen et al., 1996; Amador & Kronengold, 1998). The
underlying questions behind the empirical studies in this area thus relate to whether
impaired insight can be linked aetiologically with impaired neurocognitive func-
tion, particularly executive function, that can be found in patients with severe men-
tal illness. Studies exploring this relationship are summarised in Tables 3.6 and 3.7.
It is evident that studies claiming a significant relationship between insight and
cognitive function (Table 3.7) are roughly equal in numbers to those finding no
such relationship (Table 3.6). The two groups of studies are generally comparable in
terms of their sizes, in the range of insight assessments used, and in the range and
specificity of neuropsychology measures employed to evaluate cognitive function.
Amongst the studies suggesting an association between poor insight and impaired
cognitive function, a few find that insight relates to general cognitive function, i.e.
measures of IQ (e.g. Lysaker & Bell, 1994; Young et al., 1993; Lysaker et al., 1994;
Fennig et al., 1996), but, in general, this has not been replicated by other studies (e.g.
Takai et al., 1992; MacPherson et al., 1996; Larøi et al., 2000; Marks et al., 2000;
Drake & Lewis, 2003). The most consistent finding amongst the positive cognitive
function associations has been a correlation between some (general or selective)
impairment on performance in tests of ‘executive’ or frontal lobe function and poor
insight (Young et al., 1993; Lysaker & Bell, 1994; Lysaker et al., 1994; Voruganti et al.,
Table 3.6 Studies reporting NO association between insight and cognitive function
Insight Neuropsychology
Study Patients assessment assessment Results
Caracci n 20 Rated absent or Full scale IQ No correlation with IQ

et al. (1990) Chronic schiz. present on enquiry
(DSM-III) re-awareness of
mental illness
Takai n 57 PSE: item 104 WAIS (total, No correlation with
et al. (1992) Schiz. FBS, ratio verbal and IQ (total, verbal
(DSM-IIIR) of FBS/BPRS performance IQ) performance)
McEvoy n 43 ITAQ WMS (I, II) No correlation between
et al. (1993a) Schiz./schizaff. Peabody Picture insight and performance
(DSM-IIIR) Vocabulary Test on any tests
Bender Gestalt Test
Benton’s Controlled
Word Association
Test
Cuesta and n 40 AMDP: MMSE, WAIS (seven No correlation between
Peralta (1994) Schiz. three items subtests), Rey., Trail I and performance
(DSM-IIIR) (A, B) Making Test, (Poor I associated with
Bender’s Visual- better performance on
Motor Test, subtests verbal memory and
from Spanish delayed visual memory.)
Neuropsychological
Battery
Cuesta n 49 AMDP: WCST No correlation between
et al. (1995) Schiz, schizaff., three items I and performance on
bipolar manic WCST
(DSM-IIIR)
David n 150 SAI NART or WAIS-R No correlation between
et al. (1995) Mixed PSE: (vocab), Iager scale, I (SAI) and IQ (but PSE
psychoses item 104 Trail (A, B) Making item associated with IQ)
(DSM-IIIR) Test, tests of frontal No correlation with
lobe function any other tests
(Reitan, 1958)
Almeida n 40 SAI NART, CAMCOG, No correlation between
et al. (1996) Late PSE: Digit and Spatial I and any cognitive test
paraphrenia item 104 Span, Verbal Fluency
(ICD-9) Test, RMTW/F,
Computerised tests*
Table 3.6 (cont.)
Ghaemi n 16 ITAQ WAIS-R, WMS, No correlation between

et al. (1996) Acute mania COWAT, I and cognitive impairment
(DSM-IIIR) Finger Tapping Test,
Luria tests on visual
perception, language,
construction
Kemp and n 74 SAI NART, Verbal Fluency No correlation with
David (1996) Mixed Test, Cognitive performance on any test
psychoses Estimates Test, (Only hypothetical
(DSM-IIIR) Trail (A, B) Making contradiction associated
Test, MMSE with frontal tests scores.)
MacPherson n 64 SAI NART and MMSE No correlation with IQ
et al. (1996) Schiz. (but poor I associated with
(DSM-IIIR) worse MMSE)
Collins n 58 SAI WCST No correlation with
et al. (1997) Schiz. WCST score
(DSM-IIIR)
Dickerson n 87 PANSS: G12 WAIS-R, WMS, Rey., No correlation between
et al. (1997) Schiz./schiza WCST, Trail (A, B) I and any tests
ff. Making Test,
(DSM-IIIR) HWAST, Chicago
Fluency Test
Sanz et al. n 33 ITAQ MMSE, NART, No correlation between
(1998) Mixed SAI WCST, Star I on any measure and
psychotic IPQ prelim Cancellation Test, any tests
(DSM-IV) PANSS: G12 Trail Making Test
Carroll n 100 ITAQ NART, Quick No correlation with
et al. (1999) Schiz. Test, RBMT any test
(DSM-IIIR)
Goldberg n 211 PANSS: G12 RBANS, WCST, No correlation with IQ
et al. (2001) Schiz., bipolar, WRAT-R, WAIS-R or any test
other (DSM-IV)
Schwartz n 223 SUMD Cognitive deficits No correlation with
(2001) Schiz. (DSM-IV) from the FARS cognitive impairment
McCabe n 89 SAI Luria Nebraska No association between
et al. (2002) Chronic schiz. Neuropsychology global cognitive impairment
(DSM-IIIR) Battery and any I dimension
Table 3.6 (cont.)
(Re-labelling dimension on
SAI correlated with motor
and arithmetic functions).
Cognitive deficit failed to
predict poor insight
Arduini n 64 SUMD: abridged WCST No correlation with WCST
et al. (2003) Schiz., bipolar in either or both patient
(DSM-IV) groups
Freudenreich n 122 SUMD: modified WCST, No association between
et al. (2004) Schiz. WAIS-III – IQ, symptom awareness and
(DSM-IV) CVLT, Stroop, cognitive variables
Benton’s Controlled
Word Association Test
Mintz et al. n 253 PANSS: Cognitive Battery: No association between
(2004) Schiz. item G12 COWAT, category insight and cognition at
spectrum, fluency, verbal, baseline or at follow up
DSM-IV auditory, visual assessments
F/u: n memory, WCST,
180 at 1 year visuo-constructive
skills, attention,
Trails A,B, etc
* Computerised tests: Simultaneous and Delayed-Matching-to-Sample Task, Extra-Dimensional and Intra-

Dimensional Attention Shift Task, Spatial Working Memory Task, Tower of London Task.
Documentation of Psychopathology; BPRS: Brief Psychiatric Rating Scale; FARS: Functional Assessment
Rating Scale; FBS: Frankfurter Befindlichketsskala; I: Insight; IPQ: Insight in Psychosis Questionnaire; ITAQ:
Insight and Treatment Attitude Questionnaire; PANSS: Positive and Negative Syndrome Scale; PSE: Present
State Examination; SAI: Schedule for Assessing Insight; Schiz.: Schizophrenia; Schizaff.: Schizoaffective
Disorder; SUMD: Scale to Assess Unawareness of Mental Disorder.
Neuropsychology abbreviations: CAMCOG: Cognitive section of the Cambridge Examination for Mental
Disorders of the Elderly; COWAT: Controlled Word Association Test; HWAST: Halstead-Wepman Aphasia
Screening Test; MMSE: Mini-Mental State Examination; NART: National Adult Reading Test; RBANS:
Repeatable Battery for the Assessment of Neuropsychological Status; RBMT: Rivermead Behavioural Memory
Test; Rey.: Rey’s Complex Figure Test; RMTW/F: Recognition Memory Test for Words and Faces; WAIS (-R):
Wechsler Adult Intelligence Scale (Revised); WCST: Wisconsin Card Sorting Test; WMS: Wechsler Memory
Scale; WRAT-R: Wide Range Achievement Test-Reading.
Table 3.7 Studies reporting SOME association between insight and cognitive function
David n 91 SAI NART Better I (on SAI but not PSE)
et al. (1992) Psychotic PSE: item 104 associated with higher IQ
(PSE)
Young et al. n 31 SUMD WCST, verbal Poor I associated with worse
(1993) Chronic schiz. fluency test, performance on WCST and
(DSM-IIIR) trails A and B, worse IQ. No correlation
WAIS-R IQ with verbal fluency or trails
Lysaker and n 92 PANSS: WCST, Slosson Poor I associated with lower
Bell (1994) Schiz./schizaff. item G12 Intelligence Test IQ, poorer performance on
(DSM-IIIR) WCST
Lysaker n 85 PANSS: WCST, Slosson Poor I associated with lower
et al. (1994) Schiz./schizaff. item G12 Intelligence Test, IQ, poor performance on
(DSM-IIIR) Gorham Proverbs WCST, bizarre/
Test (GPT) idiosyncratic thought
on GPT
Lysaker and n 44 PANSS: WCST, Slosson Greater levels of cognitive
Bell (1995) Schiz./schizaff. item G12 Intelligence Test, impairment predicted less
(DSM-IIIR) Digit Symbol improvement in I
Subtest (WAIS-R),
Gorham Proverbs
Cuffel n 89 Interview rating Neurobehavioural Poor I associated with
et al. (1996) Schiz. awareness of Cognitive Status cognitive impairment
(DSM-IIIR) illness Examination
McEvoy n 32 ITAQ WAIS-R (block, Poor total I associated
et al. (1996) Schiz. vocab), Judgement with poor R-L orient
(DSM-IIIR) of Line Orientation, Subscale from ITAQ (poor
Rey., Finger awareness of mental illness)
localisation test, associated with impaired
R-L orientation, WCST, block,
COWAT, FFT, R-L orientation
WCST
Voruganti n 52 PANSS: COGLAB (includes Poor I associated with poor
et al. (1997) Schiz. item G12 WCST, vigilance, performance on span of
(DSM-IIIR) span of apprehension, apprehension, backward
illusion task, masking task and WCST
reaction time, etc.)
Lysaker n 81 PANSS: WAIS-R, WCST, Poor I associated with
et al. (1998a) Schiz./schizaff. item G12 subtests of WMSR, impaired WCST scores
(DSM-IIIR) HVLT, CPT No correlation with other
tests
Table 3.7 (cont.)
Young n 129 SUMD WAIS-R, WCST In schiz. poorer I associated

et al. (1998) Schiz., with poor performance on
bipolar WCST and poor IQ. No
(DSM-IIIR) correlation in bipolar.
Weaker in acute mania
Mohamed n 46 SUMD, subscales WAIS-R, Poorer awareness and
et al. (1999) Schiz. relating to Verbal Fluency misattribution of negative
(DSM-IIIR) negative and Test, Design symptoms associated with
positive symptoms Fluency Test, poorer performance on
Trail (B) some fluency and WCST
Making Test tasks
Larøi n 21 SUMD WAIS (Block, Poor I associated with worse
et al. (2000) Schiz. vocab), Finger performance on WCST and
(DSM-IV) Tapping Test, block design. No correlation
Kimura Figures, with IQ or any other test
WCST, Trail (A, B)
Making Test
Marks n 59 SAIQ WCST, WAIS-III Two factors from SAIQ
et al. (2000) Schiz./schizaff. PANSS: subtests, Stroop Test, correlated with WCST,
(DSM-IV) item G12 HVLT, Logical letter-number sequencing
SUMD memory of WMS, and similarities
AMNART No correlation with IQ
or other tests
Smith n 46 SUMD: WAIS-R, Worse symptom attribution
et al. Schiz./schizaff. abridged SPAN, DSDT, associated with poor
(2000) (DSM-IV) CVLT, Verbal performance on WCST
Fluency Test,
WCST, BFRT
Buckley n 50 SUMD Trail (A, B) Only poor past awareness of
et al. (2001) Schiz./schizaff. Making Test mental disorder associated
(DSM-IV) with poor TMT
performance
Chen n 80 SUMD: WCST Improvement in I correlated
et al. (2001) Psychoses abridged with improvement in WCST
and affective performance
(DSM-IV)
Upthegrove n 30 SAI-E Serial 7s, digit Poor I associated with poor
et al. (2002) Schiz. span backwards, digit span performance.
(ICD-10) working memory No other correlation
span
Table 3.7 (cont.)
Lysaker n 132 SUMD: WCST

et al. (2002) Schiz./schizaff. abridged Letter Number Poor I associated with
(DSM-IV) Sequencing of poorer executive function.
WAIS III Mixed results for partial
insight
Drake and n 33 SUMD, IS, Trail (A, B) Better I (especially
Lewis (2003) Schiz./schizaff. SAI-E, ITAQ Making Test relabelling factor)
Schiz. form, Davidhizar Frontal Lobe associated with less
delusional dis. (three I factors Score, Brixton perseveration and better set
(DSM-IV) derived) test, Hayling test, shifting. No correlation
Abstraction, with abstraction
theory of mind
visual jokes test
Rossell n 78 SAI-E WAIS-R (shortened) Poor I associated with
et al. (2003) Schiz. CPT, worse NART IQ and poorer
(DSM-IV) COWAT, visual performance on WCST-
span (WMS), categories. No other
NART correlations
Keshavan n 535 PANSS: WAIS-R, WCST, Poor I associated with
et al. (2004) Schizophrenia item G12 verbal fluency poor performance on
spectrum WMSR, RVLT, RVLT and frontal lobe
(DSM-IV) CPT tasks
Abbreviations: I: Insight; IS: Insight Scale; ITAQ: Insight and Treatment Attitude Questionnaire; PANSS:
Positive and Negative Syndrome Scale; PSE: Present State Examination; SAI: Schedule for Assessing Insight;
SAI-E: Schedule for Assessing Insight – Extended version; SAIQ: Self-Appraisal of Illness Questionnaire; Schiz.:
Schizophrenia; Schizaff.: Schizoaffective Disorder; SUMD: Scale to Assess Unawareness of Mental Disorder.
Neuropsychology abbreviations: AMNART: American version of the NART; BFRT: Benton Facial Recognition
Test; COGLAB: Cognitive Laboratory computerised test battery; COWAT: Controlled Word Association Test;
CPT: Continuous Performance Test; CVLT: California Verbal Learning Test; DSDT: Digit Span Distractibility
Test; FFT: Figural Fluency Test; HVLT: Hopkins Verbal Learning Test; NART: National Adult Reading Test; Rey.:
Rey’s Complex Figure Test; RMTW/F: Recognition Memory Test for Words and Faces; RVLT: Rey Auditory
Verbal Learning Test; SPAN: Span of Apprehension Test; WAIS (-R): Wechsler Adult Intelligence Scale
(Revised); WCST: Wisconsin Card Sorting Test; WMS(R): Wechsler Memory Scale (Revised).
1997; Lysaker et al., 1998; Young et al., 1998; Larøi et al., 2000; Drake & Lewis, 2003;
Rossell et al., 2003; Keshavan et al., 2004). However, the studies often differ in the
specific frontal lobe impairments found (Table 3.7) or some aspects/dimensions of
poor insight (McEvoy et al., 1996; Mohamed et al., 1999; Marks et al., 2000; Smith
et al., 2000; Buckley et al., 2001; Lysaker et al., 2002). Nevertheless, many other stud-
ies specifically exploring this relationship have failed to find an association between
poor insight and impairment on tests of frontal lobe function (Cuesta & Peralta,
1994, Cuesta et al., 1995; David et al., 1995; Almeida et al., 1996; Kemp & David, 1996;
Collins et al., 1997; Dickerson et al., 1997; Sanz et al., 1998; Goldberg et al., 2001;
Schwartz, 2001; Arduini et al., 2003; Freudenreich, et al. 2004; Mintz et al., 2004).
Curiously, one study reports a stronger association between poor insight and
impaired temporal lobe function (Keshavan et al., 2004).
An interesting hypothesis, attempting to explain such inconsistency of results in
studies exploring the relationship between insight and cognitive deficits, is sug-
gested by Startup (1996). He proposes that the relationship between insight and
cognitive deficits might more usefully be conceived as curvilinear on account of
the contribution of psychological or motivational factors in the manifestation of
insight. In other words, existing neurological and psychological theories put for-
ward to explain impairments of insight are not mutually exclusive and might con-
tribute proportionately according to the level of cognitive impairment suffered by
the individual. In a study involving 26 patients with schizophrenia (DSM-IIIR),
Startup administered a number of tests sensitive to frontal lobe dysfunction
(Cognitive Estimates, Verbal Fluency, Trail (B) Making Test, Stroop Test and Stylus
Maze Test), and used the ITAQ to assess insight. He was able to demonstrate that a
quadratic, rather than a linear, model could help explain the relationship between
insight and cognitive deficits, accounting for 56% of the variance. Following on
from this, Lysaker et al. (2003) carried out a cluster analysis on 64 patients
with schizophrenia spectrum disorder and, using the PANSS insight item, they
divided patients into those with good insight and those with poor insight. On
administering tests of frontal lobe function (WCST), they obtained three groups of
patients, namely, patients with good insight and average performance on WCST;
patients with poor insight and average performance on the WCST, and patients
with poor insight and poor performance on the WCST. They thus concurred with
Startup (1996) that perhaps there are subgroups of patients who may show poor
insight for different reasons: poor cognition on the one hand might underlie
problems in understanding reality in one group and a tendency to ignore or
deny unpleasant things might contribute more to impairment of insight in
another group.
Overall, however, it is evident from these studies that the relationship between
insight into mental illness and cognitive function also continues to be unclear.
3.2.7 Insight and brain structure

On the basis of similar neuro-cognitive arguments, namely, that insightlessness in
severe mental illness may be the result of cognitive deficits or even akin to anosognosia
in neurological disorders, a few studies have attempted to explore the relationship

between poor insight and structural brain abnormalities. Takai et al. (1992) found
that poor insight in schizophrenic patients was associated with ventricular enlarge-
ment on MRI. Similarly, Flashman et al. (2000) found that poor insight in patients
with schizophrenia or schizoaffective disorders was associated with smaller brain size
and intracranial volumes on MRI scanning. Patients were dichotomised into those
with and without awareness of symptoms on the basis of SUMD scores. On this
occasion, no correlations were found with global frontal lobe volumes. On the other
hand, David et al. (1995) found no association between levels of insight and ventricu-
lar enlargement on CT scanning in 128 patients with mixed psychotic disorders.
Likewise, Rossell et al. (2003) in a large MRI study found no correlation between
insight in 71 patients with schizophrenia and their grey, white, cerebro spinal fluid
(CSF) or total brain volume. A recent study by Larøi et al. (2000) examining insight
in 20 patients with chronic schizophrenia found that there was a significant associ-
ation between frontal cortical atrophy and poorer insight (SUMD). A similar finding
was reported by Flashman et al. (2001) who found that poor insight (SUMD) in
15 patients with schizophrenia correlated with reduced volumes in frontal lobe
regions. They specified further correlations between individual aspects of insight as
assessed by the SUMD and reported that unawareness of symptoms was associated
with smaller middle frontal gyrus volumes whereas misattribution of symptoms was
correlated with smaller superior frontal gyrus volumes.
3.2.8 Insight in relation to psychosocial functioning and quality of life

Questions have also been asked about the relationship between patients’ insight
into their mental illness and their level of psychosocial functioning, pre-morbid
adjustment and, more recently, various quality of life variables. Few studies, how-
ever, have addressed these questions directly and most have reported on associ-
ations with insight as secondary aims. Again, as can be seen from the summaries of
studies (Table 3.8), results are variable and inconclusive. In part at least, this is
likely to be on account of the studies examining quite different areas of function-
ing or quality of life and only few studies examining such aspects in detail.
Results of these studies can be roughly divided into three groups. A number of
studies seem to show no relation between insight and levels of psychosocial func-
tioning (Cuesta & Peralta, 1994; Ghaemi et al., 1995; Schwartz, 1998a, b; Baier
et al., 2000; Schwartz, 2001; Marková et al., 2003) or pre-morbid adjustment
(David et al., 1995). In most of these studies, the level of psychosocial functioning
was assessed by the Global Assessment Scale (Endicott et al., 1976) or its modifica-
tion in the form of Global Assessment of Functioning (APA, 1987/1994). Other
studies, on the other hand, and using a more varied range of measures of function
and quality of life (Table 3.8), suggest a relationship between poor insight and
Table 3.8 Studies reporting on association between insight and level of functioning/quality of life
Insight Measure of
Study Patients assessment function/quality Results
O’Connor n 41 SAI LSP Poor insight associated

and Herrman Residual Schiz. with worse social
(1993) (DSM-IIIR) functioning
Amador n 348 SUMD: GAS: current, Poor awareness associated
et al. (1994) Psychotic, abridged past year, past with poorer function on
affective 5 years current and past year. No
(DSM-IIIR) correlation with past
5 years
Cuesta and n 40 AMDP: GAF: current, No correlation between
Peralta (1994) Schiz. three items past year; Strauss- I and functioning
(DSM-IIIR) Carpenter Scale
Lysaker n 85 PANSS: Work Personality Poor I associated with fewer
et al. (1994) Schiz./schizaff. item G12 Profile weeks participation (work,
(DSM-IIIR) rehab), poorer social skills
and personal presentation
Peralta and n 115 AMDP: GAF current, Poor I associated with lower
Cuesta (1994) Schiz. three items past year; functioning in past year
(DSM-IIIR) SAI Strauss-
Carpenter Scale
David n 150 PSE: item 104 Maternal No correlation with
et al. (1995) Mixed interviews, pre-morbid social
psychoses pre-morbid adjustment
(DSM-IIIR) adjustment (PS)
Ghaemi n 28 ITAQ GAS No correlation with
et al. (1995) Acute mania functioning
(DSM-IIIR)
Dickerson n 87 PANSS: item G12 SFS Poor I associated with
et al. (1997) Schiz./schizaff. poorer frequency of social
(DSM-IIIR) activities
Lam and n 40 SAI SPS Poor insight weakly
Wong (1997) Bipolar 1 associated with lower level
(DSM-IV) of social functioning
Debowska n 61 PANSS: item G12 CSPAS Poor I associated with
et al. (1998) Paranoid schiz. pre-morbid adjustment
(DSM-IIIR) disorders in early
adulthood
Table 3.8 (cont.)
Insight Measure of
Lysaker n 101 SUMD: QOL Poor I (particularly

et al. (1998b) Schiz./schizaff. abridged awareness of social
(DSM-IIIR) consequence of illness)
associated with poorer
social function
(independent of deficit
symptoms)
Schwartz n 64 PANSS: GAF No correlation with

(1998a) Schiz. item G12 psychosocial functioning
(DSM-IV)
Schwartz n 66 SUMD GAF No correlation with

(1998b) Schiz. psychosocial functioning
(DSM-IV)
Doyle n 40 IS: median score SOL-I No correlation between I

et al. (1999) Acute schiz. divided patients LQOLP and quality of life scores
(DSM-IIIR) into high I But patients with high
(n 20) and insight had positive
low I (n 20) correlation with objective/
subjective indicators of
quality of life
Smith n 46 SUMD SBS Poor I associated with

et al. (1999) Schiz./schizaff QOLI social behavioural deficits
(DSM-IV) Subjective quality of life not
correlate with I
Baier et al. n 37 IS GAF No correlation with
(2000) Schiz./schizaff. DSS psychosocial functioning
Larøi n 21 SUMD GAF Poor I associated with worse
et al. (2000) Schiz. psychosocial functioning
(DSM-IV)
White et al. n 150 SAI QOLI Higher I associated with
(2000) Schiz. Items from IMSR more close friends and
(DSM-IV) GAF, GARF family but with less
satisfaction with
relationships
Francis and n 29 ITAQ Social skills and Better I associated with
Penn (2001) Schiz./schizaff. PANSS: item interactions in two better social skill, less
Table 3.8 (cont.)
Insight Measure of
and bipolar G12 contexts taped strangeness, greater

(DSM-IV) IS and rated; CES self-disclosure of
mental illness. No
correlation with specific
social skills (eye contact,
fluency, fidgeting, etc.)
Goldberg n 211 PANSS: BQOLI Better I associated

et al. (2001) Psychoses item G12 Overall social with better overall
and affective and non-verbal social skills. No correlation
(DSM-IV) skills with non-verbal skills or
quality of life
Pini et al. n 236 SUMD GAF Some dimensions of I

(2001) Psychoses and associated with GAF:
affective poor awareness of
(DSM-IIIR) anhedonia and a sociality
associated with worse
psychosocial function
Schwartz n 223 SUMD FARS No association with

(2001) Schiz. self-care deficits, inter-
(DSM-IV) personal problems or
family relationship problems
Marková n 64 IPQ GAS No correlation with

et al. (2003) Schiz. PSE: item 104 functioning
(DSM-IV)
Documentation of Psychopathology; BQOLI: Brief Quality of Life Interview; CES: Customer Experience of
Stigma; CSPAS: Cannon-Spoor Premorbid Adjustment Scale; DSS: Davidhizar et al. – Self-Rating Scale for
Insight; FARS: Functional Assessment Rating Scale; GAF: Global Assessment of Functioning; GARF: Global
Assessment of Relational Functioning; GAS: Global Assessment Scale; I: Insight; IMSR: Interview Measure of
Social Relationships; IPQ: Insight in Psychosis Questionnaire; IS: Insight Scale; ITAQ: Insight and Treatment
Attitude Questionnaire; LQOLP: Lancashire Quality of Life Profile; LSP: Life Skills Profile; PANSS: Positive
and Negative Syndrome Scale; PSE: Present State Examination; QOL: Quality of Life Scale (Heinrichs et al.,
1984); QOLI: Quality of Life Interview (Lehman, 1988); SAI: Schedule for Assessing Insight; SBS: Social
Behaviour Scale; Schiz.: Schizophrenia; Schizaff.: Schizoaffective Disorder; SFS: Social Functioning Scale; SOL-I:
Standard of Living Questionnaire; SPS: Social Performance Schedule; SUMD: Scale to Assess Unawareness of
Mental Disorder.
poorer psychosocial function and quality of life (O’Connor & Herrman, 1993;
Lysaker et al., 1994; Peralta & Cuesta, 1994; Dickerson et al., 1997; Lysaker, et al.,
1998b; Larøi et al., 2000; Pini et al., 2001). One study reports that poor insight is
associated with some pre-morbid adjustment disorders in late adolescence and in
early adulthood (Debowska et al., 1998). Finally, there are studies, which yield
mixed results and generally these employ more detailed measures of different
aspects of psychosocial functioning and/or quality of life. For example, using the
Quality of Life Interview together with a Social Behaviour Scale, Smith et al. (1999)
found that whilst poor insight in schizophrenic/schizoaffective patients was related
to social behavioural deficits, their subjective quality of life assessments were not
related to insight. In contrast, White et al. (2000) found that better insight in
patients with schizophrenia was related not only to having more close friends and
family but also to less satisfaction with their relationships. And other studies, also
using more detailed social skills and quality of life measures, have suggested that
poor insight relates to impairment in some social skills but not in others (Francis &
Penn, 2001; Goldberg et al., 2001).
3.2.9 Insight and psychiatric diagnosis

Do patients with schizophrenia have worse or a different sort of insight into their
illness than patients with other mental disorders? Does insight depend to some
extent on the type of mental disorder affecting an individual? Perhaps surprisingly
such questions have not been addressed to any great extent. Overwhelmingly,
empirical studies exploring insight into mental disorders have tended to focus pre-
dominantly on patients with schizophrenia and schizoaffective disorders. Of the
studies that have included patients with various psychoses and affective disorders,
only some have reported on any differences in insight held between different
patient groups (Table 3.9).
Little can be said conclusively on the basis of the results summarised. Some
studies suggest no significant differences in insight between different patients
groups (David et al., 1992; David et al., 1995; Arduini et al., 2003). Other studies
point to differences between diagnostic groups but the differences themselves are
variable. Most of these studies indicate that patients with schizophrenia seem to
show less insight than patients in other diagnostic groups (Amador et al., 1994;
Michalakeas et al., 1994; Fennig et al., 1996). Nevertheless, some investigations
claim that patients with schizophrenia have similar levels of insight to patients
with bipolar and other psychotic disorders but poorer insight than that of patients
with schizoaffective or other affective disorders (Weiler et al., 2000; Pini et al.,
2001). On the other hand, other studies suggest that insight in schizophrenic
patients is similar to that of schizoaffective patients (Cuesta et al., 2000; Smith
et al., 2000) or even better than that of schizoaffective patients and manic patients
Table 3.9 Studies reporting on differences in insight between diagnostic groups
Insight
Study Patients assessment Results
Greenfeld n 21 Interview along Patients with depression more

et al. (1989) (SZ-9, BP-5, Unip.-4, defined dimensions likely to attribute psychosis to
atypical psychology: physical illness
three) DSM-III
David et al. n 91 SAI No difference in degree of I between

(1992) (SZ-52, paranoid PSE: item 104 patients with SZ and those
psychosis 12, with other diagnoses
depressive psychosis 7,
manic psychosis 4,
mixed aff. and
neurotic – 11,
uncertain – 5)
PSE CATEGO
Amador n 348 SUMD: Patients with SZ showed greater

et al. (1994) (SZ-221, SA-49, BP-40, abridged deficits in awareness than any other
PMDD-24, non- diagnostic group. Patients with BP
psychotic MDD-14) (mania) showed similar levels of
DSM-IIIR unawareness except had more
awareness into delusions
Michalakeas n 77 (women) ITAQ Patients with SZ had poorest I,

et al. (1994) (SZ-42, Mania-13, followed by patients with mania,
MDD-22) and patients with MDD had
DSM-IIIR highest I
David et al. n 150 PSE: item 104 No difference in I between

(1995) (SZ-69, SA-12, diagnostic groups
AP-38, OP-31)
DSM-IIIR
Swanson n 41 Clinical Patients with SZ less I than patients

et al. (1995) (SZ-21, Mania-20) vignettes with Mania
DSM-IIIR
Fennig n 189 Insight item I highest in PD. Majority of BP

et al. (1996) (SZ-86, BPp-52, from HDRS gained I at f/u. SZ – poor I and
PD-35, OP-16) less change over time
Kemp and n 74
David (1996) (SZ-43, SZF-7, BPm-17, SAI Insight higher in non-SZ diagnostic
BPd-3, SA-4) DSM-IIIR groups
Table 3.9 (cont.)
Insight
Study Patients assessment Results
Sanz et al. n 33 ITAQ, SAI Patients with BPm and SA had

(1998) (SZ-18, SA-6, IPQ prelim lowest I, followed by SZ, whilst
BPm-6, PD-3) PANSS: item G12 patients with PD
DSM-IV had highest I (only with SAI)
Young et al. n 129 (SZ-108, BP-21 SUMD No difference in I between SZ
(1998) [12 manic]) DSM-IIIR and BP (but when mania excluded,
then poorer I in SZ)
I in SZ was global correlating with
other aspects of self-awareness
(not the case for I in BP)
Weiler et al. n 187 ITAQ Patients with SZ, BP and other
(2000) (SZ-81, BP-40, MDD-33, psychoses had poorer I than SA and
SA-14, other-19) DSM-IIIR MDD. At d/s, patients with ‘other’
psychosis had lowest I
Cuesta et al. n 75 (SZ-37, SA-11, SUMD, ITAQ, Patients with SZ and SA had similar
(2000) AP-27) DSM-IV AMDP: three items I but worse than patients with AP
Goldberg n 211 (Psychotic: PANSS: item G12 Patients with mood disorders
et al. (2001) mostly SZ/SZF-158, (including BP) had better I than
Mood: mostly BP-52) patients with psychotic disorders
DSM-IV
Pini et al. n 236 SUMD Patients with SZ had poorer I than
(2001) (SZ-29, SA-24, BP-153, SA and Unip. but same level of I
UD-30) DSM-IIIR as BP
Arduini n 64 SUMD: No difference in degree of I
et al. (2003) (SZ-42, BP-22) DSM-IV abridged between patients with SZ and BP
Eisen et al. n 149 (OCD-64, BABS Patients with BDD had poorer
(2004) BDD-85) DSM-IV I than patients with OCD
Documentation of Psychopathology; AP: Affective Psychosis; BABS: Brown Assessment of Belief Scale; BDD:
Body Dysmorphic Disorder; BP: Bipolar Affective Disorder; BPd: Bipolar Depression; BPm: Bipolar Manic; BPp:
Bipolar Psychotic Disorder; HDRS: Hamilton Depression Rating Scale; I: Insight; IPQ: Insight in Psychosis
Questionnaire; ITAQ: Insight and Treatment Attitude Questionnaire; MDD: Major Depressive Disorder without
psychosis; OCD: Obsessive Compulsive Disorder; OP: Other Psychosis; PANSS: Positive and Negative Syndrome
Scale; PD: Psychotic Depression; PMDD: Major Depressive Disorder with Psychosis; PSE: Present State
Examination; SA: Schizoaffective Disorder; SAI: Schedule for Assessing Insight; SUMD: Scale to Assess
Unawareness of Mental Disorder; SZ: Schizophrenia; SZF: Schizophreniform Disorder; UD: Unipolar Depression.
(Sanz et al., 1998). Factors likely to contribute to the inconsistencies in this area
include not just the differences in insight assessments but also the specific diag-
nostic criteria used. In addition, the proportions of patient numbers in the differ-
ent diagnostic categories vary considerably across the studies described.
There have been few systematic empirical studies exploring insight in conditions
other than the various psychoses. Why the exploration of insight empirically should
be limited to the psychoses is not so clear, except presumably that since loss of
insight has long been intrinsic to the definitional criteria of certain psychotic symp-
toms such as delusions (Berrios, 1994b), examination of insight has been promoted
by the conditions where its loss is so dramatically apparent. Indeed, as far as the
so-called anxiety, dissociative disorders, milder depressive disorders, etc. (i.e., those
conditions traditionally conceived in the ‘neurotic’ sphere where, conventionally,
insight is assumed to be present), are concerned, much of the empirical work has
taken place predominantly in the psychodynamic field (Chapter 2). However, it is of
interest, that some of the traditional views concerning the notion that the presence
of insight can be used as a criterion to differentiate between the psychoses and the
so-called neuroses have begun to be challenged in practical as well as in theoretical
ways. For example, in recognition of the increasingly common observations that
patients with obsessive-compulsive disorders (OCD) show a wide range of insight,
particularly as far as regarding their obsessions/compulsions as senseless is con-
cerned (e.g. Insel & Akiskal, 1986; Lelliott et al., 1988), then the DSM-IV Field Trial,
using a structured scale, specifically explored insight in 431 patients with OCD (Foa &
Kozak, 1995). Their conclusions, confirming that patients with OCD do show a
range of insight resulted in a change made to the previous definitional criteria of
DSM-IIIR, and a new specifier of ‘OCD with poor insight’ was introduced into
DSM-IV (American Psychiatric Association, 1994). Nevertheless, there has not yet
been much work exploring the relationship between insight in patients with OCD
and other clinical correlates. Some small earlier studies yield mixed results. For
example, one study suggested that patients with poor insight into their obsessions/
compulsions showed worse clinical outcome after exposure treatment (Foa, 1979).
On the other hand, a larger study by Lelliott et al. (1988) found no difference in out-
come following behaviour therapy between those patients with and without insight.
Another more recent study found that patients with poorer insight in OCD (i.e.
patients who had strong beliefs in the feared consequences of not carrying out
their compulsions) had worse outcome following behaviour therapy than those
who expressed less strong beliefs in the consequences of not carrying out their
compulsions (Foa et al., 1999) (Table 3.4). However, the same study also found that
patients who showed less insight into their OCD (in terms of articulating fears con-
cerning consequences of obsessional beliefs) seemed to benefit more from the
behaviour treatment than those who showed better insight. In other words, the
researchers found different types of outcome according to level or severity of poor

insight expressed by the patients. Using a semi-structured rating scale assessing
insight in 71 patients with OCD, Eisen et al. (2001) found that insight improved as
symptoms of OCD improved though insight itself was not found to be a predictor
of clinical response to pharmacotherapy. The semi-structured rating scale used in
the study, the Brown Assessment of Beliefs Scale (BABS), was originally devised to
assess delusional beliefs in terms of components of insight, such as conviction, fix-
ity of belief, response to different explanations, perceptions of others’ views, etc.
(Eisen et al., 1998). Again, this arose in recognition of the observation that patients
with delusions showed a range or continuum of insight and hence delusional beliefs
should not, simply by definition, be associated with insightlessness. Using the same
semi-structured rating scale assessing insight into beliefs, Eisen et al. (2004) com-
pared insight in patients with obsessive-compulsive disorder and those with body
dysmorphic disorder (BDD). The authors found that patients with BDD had sig-
nificantly worse insight than patients with OCD even though severity of illness was
comparable in the two groups. The authors suggested that it was the type of beliefs
held by the BDD group that was significant, particularly beliefs around others’ per-
ception of patients’ views, as well as more delusional ideation that contributed to
the poorer insight held.
Greenfeld et al. (1991) carried out a longitudinal study exploring insight in
30 patients with Anorexia Nervosa. Using their structured schedule for assessment
of insight, they found that the presence of insight predicted clinical outcome
(Table 3.4). In contrast to the results reported in relation to changes in insight over
time (e.g. McEvoy et al., 1989b), patients with anorexia nervosa were found to
maintain a relatively consistent level of insight between their acute illness (hospi-
talisation) and follow-up (after discharge from hospital). The other interesting and
contrasting finding (compared with much of the work on insight in psychoses),
was that the researchers reported a correlation between high levels of global insight
and more severe illness (in terms of degree of emaciation and longer hospital
admissions) (Table 3.5). The authors speculated that perhaps the longer duration
of hospital admission as well as the more severe emaciation promoted patients to
confront their illness and to learn about the reality of their problems. These are
interesting issues raised by the studies, both in OCD/BDD and in anorexia ner-
vosa, but there needs to be much more research in these areas and in other non-
psychoses disorders in order to develop further understanding about the nature of
insight in these conditions.
Only some studies have explored insight empirically solely in affective disorders
(Ghaemi et al., 1995; 1996; Ghaemi et al., 1997; Peralta & Cuesta, 1998; Pallanti
et al., 1999; Cassidy et al., 2001; Yen et al., 2003) and these vary in their aims. Thus,
the studies by Ghaemi et al. (1995; 1996) examined insight in patients with acute
mania and found that patients tended to show poor insight and that this did not
improve over the course of hospital admission. In contrast, Yen et al. (2003)
reported an overall improvement in insight in patients with mania as their manic
symptoms resolved though they found also that in some cases patients’ insight
remained either unchanged or worsened. Pallanti et al. (1999), on the other hand,
focusing on clinical differences between patients with bipolar I and II disorders,
found that patients with bipolar II disorders seemed to show poorer insight than
bipolar I patients. A different study, reported by Peralta and Cuesta (1998), explored
differences in insight (using the AMDP: 3 items) between patients with mania
(n 21) and patients with depression (n 33) and looked at the effects of psych-
otic symptoms in relation to insight. They found that manic patients tended to
show less insight than depressed patients, that patients with depression and psych-
otic symptoms had less insight than those with depression and without psychotic
symptoms (this same association with psychotic symptoms did not hold for
patients with mania), and that mood-congruent and mood-incongruent psychotic
symptoms did not differ in relation to contributing to insight. In another approach,
Ghaemi et al. (1997) examined insight change in patients with seasonal affective
disorder before and after light therapy, and found higher levels of insight associated
with more severe depressive ratings but no significant change in insight following
treatment. Lastly, and in yet a different vein, the study by Cassidy et al. (2001)
explored differences in insight between patients with pure manic disorders (n 42)
and those with mixed manic disorders (n 11). Using the ITAQ, they found that
patients with the mixed manic episodes showed greater insight than those with pure
manic episodes and linked this with more depressive symptoms experienced by the
former. Again, as with other variables, no definitive statements can be made con-
cerning the nature of insight in relation to affective disorders. However, the studies
do raise the issue of the relationship between depression and insight.
3.2.10 Insight and depression

Questions around the relationship between insight and depression have tended to
be embedded, generally speaking, within the psychological and motivational con-
ceptions of the nature of insight. In other words, within these frameworks, impair-
ment of insight in relation to mental disorders is viewed as a form of denial, a
strategy employed to protect the self from the psychological consequences of hav-
ing knowledge about a particular disorder and its effects. It would follow, there-
fore, that patients with greater insight, or less denial, by understanding more fully
the implications of having a particular disorder, would naturally be likely to
become distressed or depressed. In general, empirical studies exploring associ-
ations between insight and depression have sought to either support or disprove
this broad premise. More recently, related cognitive models couching the possible
relationship between insight and depression in terms of self-esteem factors, have

also been proposed though empirical results have not been conclusive (Iqbal et al.,
2000; Drake et al., 2004).
As already seen in the previous section (Table 3.9), there is some suggestion that
patients with depressive disorders show better insight into their illness than
patients with schizophrenic/schizoaffective/other psychotic disorders. Cassidy
et al. (2001) study indicated, in addition, that patients with mixed manic states (i.e.
with increased depressive symptoms) had more insight than patients with pure
manic states (without depressive symptoms). However, as was discussed, numbers
of studies are small and results are variable.
Clearly, by far the most empirical studies on insight have been carried out in
patients with schizophrenia and other psychotic disorders. In these studies, there-
fore, depression tends to be rated on the basis of presence of depressive symptoms
or patterns of depressive symptoms usually by adding cumulative scores on
depressive items from general psychopathology instruments or occasionally using
depressive rating scales such as the Hamilton Depression Rating Scale or the
Calgary Depression Rating Scale. Thus, several studies have reported on the asso-
ciation between insight and degree of depression. Results here, as in other areas,
are variable. However, most of the studies do seem to find an association between
better insight and worse depression (Smith et al., 1998; 2000; Carroll et al., 1999;
Moore et al., 1999; Iqbal et al., 2000; White et al., 2000; Pyne et al., 2001; Schwartz,
2001) though some studies have qualified this association on longitudinal follow-
up finding that better insight is associated with worse depression at baseline
but not at 6 weeks (Kemp & Lambert, 1995), 12 months (Mintz et al., 2004) or 18
months follow-up (Drake et al., 2004). Some studies find this association only with
some aspects of insight, e.g. the Amador et al. (1994) study found that schizo-
phrenic patients with depressive symptoms showed better awareness of specific
symptoms (current thought disorder, blunt affect, anhedonia) than schizophrenic
patients without depressive symptoms. Similarly, the study by Carsky et al. (1992)
showed that patients with greater acknowledgement of symptoms and poor func-
tioning had more depressive symptoms but that this association did not hold in
relation to acknowledgement of the need for treatment. Some studies find no rela-
tionship between insight and depression in mixed psychotic patients (Amador
et al., 1993; Kim et al., 1997; Cuesta et al., 2000), and a few studies apparently find an
association in the opposite direction, i.e., poor insight (or aspects of insight) asso-
ciated with worse depression (O’Connor & Herrman, 1993; Collins et al., 1997;
Buckley et al., 2001; Sevy et al., 2004). An interesting study, explicitly testing a
hypothesis of psychological mechanisms underlying insight (specifically invoking
mechanisms of self-deception), was reported by Dixon et al. (1998). Using a
discrepancy method of assessing insight (i.e. differences between patients’ and
relatives’ evaluations) in 41 schizophrenic patients, they found that subjective

ratings (i.e. those made by patients) of worse depression were associated with
increased insight. In contrast, objective ratings (i.e. those made by relatives) of
worse depression were associated with poorer insight. Subjective increased depres-
sion was also associated with greater insight into psychotic illness in the study by
Sanz et al. (1998).
Related to the ideas about insight and depression, some investigations have also
examined the association between insight and suicidal thoughts/behaviour in
schizophrenic patients. In Amador et al. (1996) study, patients were categorised
into those with and without recurrent suicidal thoughts/behaviours. An associ-
ation was found between only some aspects of insight and suicidal thoughts. Thus,
patients with greater awareness of specific symptoms (delusions, asociality,
blunted affect, anhedonia) showed more suicidal thoughts and behaviours.
Similarly, Schwartz and Petersen (1999) found a specific association between suici-
dality ratings (on the FARS) and only some aspects of insight. They found that
only increased insight into the need for treatment was associated with increased
suicidality ratings, whereas there was no such association with insight into mental
disorder or into its social consequences. This finding contrasts (if depressive symp-
toms and suicidal thoughts are taken as reflecting similar distress) with Carsky
et al. (1992) study where no relationship was found between depression and
insight into need for treatment but it was found between depression and insight
into mental illness. Recent longitudinal studies of patients with schizophrenia
spectrum disorders found that patients with good insight had experienced more
suicidal attempts than those with poor insight (Bourgeois et al., 2004; Mintz et al.,
2004). Bourgeois et al. (2004) suggested that depression and hopelessness were fac-
tors mediating this. They also reported that changes in insight associated with
treatment over 2 years helped reduce risk of suicide attempts. The association
between insight and depression was found at baseline measurements but not at
1-year follow-up in the study by Mintz et al. (2004).
3.2.11 Insight and compliance with treatment

Poor compliance with treatment is a source of major problems in the management
of patients with severe mental illness as it carries important implications for
patients’ well-being and prognoses (McEvoy, 1998). Increasingly, research has
focused on determining possible factors which influence compliance and which
could be used to find new ways of improving adherence to treatments (Buchanan,
1992; Kemp & David, 1996). The role that insight into mental illness might have in
relation to compliance with treatments has been examined in several studies. Most
such studies suggest that poorer insight into illness is associated with poorer com-
pliance with treatments (Lin et al., 1979; Marder et al., 1983; Bartkó et al., 1988;
McEvoy et al., 1989b; Amador et al., 1993; MacPherson et al., 1996; Mutsatsa et al.,
2003) though some suggest only a weak correlation (Van Putten et al., 1976) or no
correlation (Taylor & Perkins, 1991) and even a negative relationship (Whitman &
Duffey, 1961). McEvoy et al. (1989a, b) found that schizophrenic patients with bet-
ter insight on hospital admission (ITAQ) were more compliant with treatments at
initial and early assessments but that good insight at this stage did not associate
with compliance at long-term (2–3 year) follow-up. Similar results were reported
by Cuffel et al. (1996) in their study of 89 schizophrenic patients in that better
insight (based on semi-structured interview addressing patients’ recognition of ill-
ness and need for psychiatric treatment) was associated with recent adherence to
outpatient treatment and medication but not with later use of services and adher-
ence to medication.
Studies examining the relationship between insight into mental illness and com-
pliance with offered treatments are, however, particularly difficult to interpret.
Some of the problems relate to the difficulty in evaluating treatment adherence
itself (McEvoy, 1998) but the main problem concerns the assessments of insight in
these circumstances and the consequent meaningfulness of results. Specifically, the
problem consists of the circularity that results when insight is defined, in part at
least, by acceptance of treatment (e.g. Lin et al., 1979; McEvoy et al., 1989a; David,
1990; Buchanan, 1992; Amador et al., 1993; Cuffel et al., 1996). Rating insight then
becomes tantamount to rating verbal compliance and difficulties arise in deter-
mining the individual aspects of the putative explored relationship. It is not that it
is invalid to address the question of a relationship between verbal compliance with
treatment and actual adherence to treatment for that will necessarily provide
important information in terms of understanding views and concerns of patients,
and help to plan future management. Indeed, studies have shown that there is not
a direct relationship between articulated attitudes towards treatment and actual
behavioural adherence (McEvoy et al., 1989b). The issues here, however, are two-
fold. First is the question of whether there are any theoretical grounds to consider
verbal compliance with treatment as a component of insight (Marková & Berrios,
1995a; McCabe et al., 2000). Second is the question whether it is meaningful to
treat verbal compliance qua insight as a variable against which actual treatment
adherence is assessed (David, 1990; Lambert & Baldwin, 1990). Interestingly, there
is some suggestion from the few studies where insight assessment does not, to any
great extent, incorporate attitudes to treatment, that the relationship between
insight and adherence to treatment is more complicated. For example, in the study
by Goldberg et al. (2001), better insight (assessed by the PANSS: item G12) was
associated with more positive attitudes towards medication but was not correlated
with self-reported ratings of medication compliance. And, similarly, the study by
Sanz et al. (1998) which compared insight evaluated by different scales found that
better insight, as assessed by ITAQ, SAI and PANSS, showed significant association
with adherence to medication, as well as compliance with attendance at mental
health centres. However, insight assessed by the IPQ (preliminary version) did not
correlate with medication adherence although it did relate to continued contact
with mental health centres.
3.2.12 Insight and other clinical variables

Lastly, there are a few studies examining the relationship between insight and other
clinical features which are interesting but which, because of the lack of sufficient
work in these areas, can do little more than suggest further avenues of exploration.
Taylor and Perkins (1991), e.g. explored the relationship between ‘insight’
(denial/exaggeration of problems) and patients’ feelings of identity, i.e., in regards
to whether patients related more to feeling as ‘community members’ or as
‘patients’. Contrary to their expectations, they found no association between
patients’ perceived identities and denial of illness. On the other hand, McEvoy et al.
(1996) examined the relationship between schizophrenic patients’ insight and
their social understanding or common sense. Using the Social Knowledge
Questionnaire, to determine patients’ understanding of social behaviours, and the
ITAQ to assess insight, they found that higher insight was related to better social
knowledge in 32 patients with schizophrenia. Interestingly, using the SAI to assess
insight, Upthegrove et al. (2002), also examining the association between insight
and social knowledge in schizophrenic patients (n 30), found no association
between levels of insight and social knowledge, and argued for independence of
these concepts. From a slightly different perspective, Vaz et al. (2002) examined
social interaction (using the Social Cognitions and Object Relations Scale
(SCORS)) as a form of social knowledge about the environment in patients with
schizophrenia, and found a correlation between good insight (SAI) and under-
standing of social causality dimension on the SCORS. They posited the import-
ance of conceiving insight as a multidimensional structure that needs to take
account of a wider context of social knowledge and interpersonal relationships.
Another viewpoint in relation to insight was examined by Lysaker et al. (1999)
in their investigation of likely personality factors that could be important in con-
tributing to insight and changes in insight in patients with schizophrenic dis-
orders. Their study suggested that some personality factors, such as extraversion
and psychoticism, might be predictive of fewer fluctuations in insight over time. In
a later study, Lysaker et al. (2002) examined the relationship between patients’
insight and coping style (using avoidance and positive reappraisal scales of the
Ways of Coping Scale). They reported that, in their sample of 132 patients with
schizophrenia or schizoaffective disorders, patients unaware of their symptoms
showed a greater preference for positive reappraisal than partially aware or
unaware patients (SUMD). In addition, they found that patients unaware of the
consequences of their illness endorsed a greater preference for escape-avoidance as

a coping style. Within the acknowledged limitations of the study design, the
researchers suggest that, perhaps, different types of coping strategies might be dif-
ferentially related to deficits in different aspects of insight and raise the importance
of exploring this further particularly in terms of developing and enhancing rehabili-
tation strategies. Indeed, in another study, Lysaker et al. (2003) found that a sub-
group of patients (schizophrenia spectrum disorders) with poor insight and
average executive function (WCST) scored significantly more on the distancing
(passive dismissal) coping strategy than patients with poor insight and impaired
executive function. Discussion in these areas can only be speculative at this point
but the issue is highlighted that insight in its multidimensional sense may be
underpinned by a variety of different mechanisms.
In a novel approach seeking to modify patients’ insight into their psychoses by
allowing self-observation into their acute psychotic state by means of videotapes,
Davidoff et al. (1998) found that patients’ insight into their illness improved com-
pared with those patients not exposed to such videos despite comparable levels of
psychopathology. The researchers thus suggested that self-observation in recovered
patients of their acute illness may be a useful means of developing patients’ insight.
Moore et al. (1999) explored levels of self-deception or denial in schizophrenic
patients using the Balanced Inventory of Desirable Responding. They found that
patients with poorer insight had fewer depressive symptoms and had higher scores
on the self-deception measure, and suggested that the mechanism of impaired
insight in these patients might relate to the psychological process of denial.
A few studies have looked at the relationship between patients’ insight into men-
tal illness and their insight into abnormal movements (dyskinesia), and generally
found that poor insight into mental disorder is associated with poor insight into
involuntary movements (Caracci et al., 1990; Cuesta & Peralta, 1994; Arango et al.,
1999). Using the SUMD, Arango et al. (1999) found that unawareness of dyskinesia
correlated only with some aspects of poor insight into mental illness. They also
reported that schizophrenic patients with the deficit syndrome had less awareness of
abnormal movements than those without a deficit syndrome and that unawareness
of dyskinesia was not related to the severity of the dyskinesia itself. The latter find-
ing was likewise reported by Macpherson and Collis (1992) who also suggested that
patients with manic-depressive psychoses (ICD-9) were significantly more likely to
be aware of their tardive dyskinesia than patients with schizophrenia. However, the
nature of the relationship between insight into such drug-induced abnormal motor
movements and into mental illness itself has not been the focus of much conceptual
or theoretical work. It is therefore difficult to infer very much in terms of under-
standing insight or its relationships on the bases of these empirical studies alone.
However, they do raise important issues that need to be considered particularly as
far as insight as a relational concept is concerned (Chapter 7).
Other occasional correlations have been sought between insight into mental dis-
order and different clinical variables. For example, Cuesta and Peralta (1994)
found no association between insight into mental disorder and the presence of
neurological soft signs. The rationale in examining this relationship was to look for
an association between neurological/cognitive dysfunction (using the soft neuro-
logical signs as proxy ‘organic’ variables) as a mechanism to ‘explain’ poor insight.
3.3 Conclusion
Over the last 15 years considerable interest has been taken in the empirical explor-
ation of insight in patients with mental illness and predominantly those with psych-
otic disorders. Whilst clinical interest in the notion of insight has been apparent
since insight was conceptualised as a clinical phenomenon, this specific research
interest seems to have been generated following the relatively recent attempts at the
operationalisation of the concept of insight. In turn, this has resulted in the devel-
opment of a number of structured measures of insight thus facilitating its quanti-
tative assessment and hence encouraging the surge of correlational studies.
In different ways, the underlying purpose of empirical studies, whether explicitly
stated or implicitly understood, has been to elucidate the nature of insight as a clin-
ical phenomenon. The primary questions have focused on three main issues. First
has been the question concerning the extent to which impairment of insight could
be considered intrinsic to the mental illness process itself. Thus, studies have exam-
ined the relationship between patients’ insight and clinical variables related to the
mental disorder, such as severity of illness, specific symptomatology, cognitive
impairment, brain dysfunction, etc. Second has been the question concerning the
extent to which impaired insight could be considered as an individual reaction to
the mental illness. In order to try to answer this, studies have examined the associ-
ation between patients’ insight and various mood disorders or reactions or specific
personality variables. Third has been the question concerning the extent to which
patients’ insight might be shaped by individual and external or environmental fac-
tors. Studies have attempted to explore this by examining the relationship between
patients’ insight and socio-demographic variables, cultural factors, past experi-
ences, educational/social knowledge, etc. Secondary questions explored by empir-
ical studies have related mainly to the clinical implication of having impairment of
insight, i.e., whether insight can be considered a prognostic factor and consequently
whether efforts should be made to help change patients’ insight.
It is evident, however, that clear or definitive answers to the above questions
are difficult to obtain. As this chapter has shown, the outcomes of empirical studies
in these areas yield, to varying extents, mixed and inconclusive results. Whilst
differences in study methodologies, e.g. patient samples (diagnostic categories,
acute/chronic, numbers, outpatients/inpatients, etc.) and outcome measures, are

likely to contribute to this variability in results, a significant factor must be to do
with the difficulties involved in ‘capturing’ insight empirically. As is apparent, such
difficulties reside in a number of areas. Firstly, the conceptualisation of insight the-
oretically has proved complex and work in this area has demonstrated this in the
wide range of definitions proposed. Such definitions vary in specificity, breadth,
focus and their detail or components. The numbers and range of definitions put
forward are reflective of the inherent complexity of the concept of insight itself and,
indeed, the view of insight as a multidimensional structure has become the dom-
inant conceptualisation amongst researchers. Secondly, and as a result of different
definitions of insight, various assessment instruments have been devised, differ-
ing in contents (types and specificity of judgements, details, etc.), in the way in
which insight is elicited (clinician versus self-ratings), the ratings employed (cate-
gorical/continuous scores), etc. Thirdly, additional difficulties are posed by the
problems of the translation process itself, i.e., the conversion from a theoretical con-
cept of insight to an empirical measure designed to capture the identified compon-
ents of the theoretical construct. The various measures that have been detailed in
this chapter reflect to different extents the researchers’ original conceptualisation.
For all these reasons, it is perhaps not surprising that empirical studies exploring the
relationship between patients’ insight and clinical variables yield such mixed results.
The fact that so far empirical work has been unable to produce conclusive results
should not, however, detract from the importance of the research carried out in this
area. What is raised and highlighted by these studies is the complexity of the concept
of insight, its relational nature (Chapter 7) and the issue that different aspects of
insight are elicited in different studies and by different methods and are likely to be
important in different ways and for different reasons. Consequently, future work
needs to look again at firstly exploring the structure of insight at a conceptual or the-
oretical level, which would enable the clearer delineation of specific aspects of
insight. Secondly, work needs to address the problems and limitations of the transla-
tion process so that the clinical phenomena of aspects of insight can be more clearly
demarcated. Only then, decisions can be made concerning which aspects of insight
might be usefully examined in relation to particular variables. These issues are
explored in more detail in Part II.
4
Insight in organic brain syndromes: insight

into neurological states
4.1 Introduction
Over the past 10–15 years, and paralleling the interest in the empirical examination
of insight in ‘functional’ psychiatric disorders, there has likewise been a prolifer-
ation of studies focusing on exploring patients’ insight into organic brain syndromes,
particularly, dementias (Marková & Berrios, 2000; Clare, 2004). Studies in this area
have concentrated predominantly on examining the relationship between patients’
insight and clinical variables, e.g. the severity or type of brain lesion/dementia, the
presence of affective disorder, etc. There has been, in addition, more emphasis on
developing specific measures to assess insight as well as on exploring possible neuro-
logical and neuropsychological mechanisms underlying impaired insight. As with
studies on insight in functional psychiatric disorders, outcomes have yielded
variable and inconsistent results (Marková & Berrios, 2000). Many of the problems
encountered in the empirical study of insight in functional psychiatric disorders,
such as, differences in the definitions of insight and underlying concepts, differences
in methods of assessing insight and different outcome measures employed, are likewise
evident in the studies of insight in patients with dementia and are likely to be
contributing to the variability in results. However, there are, in addition, issues
more specific to the exploration of insight in dementia and these also need to be
considered.
Firstly, the clinical status of the dementias themselves is of particular significance.
Dementias, or chronic organic brain syndromes, are conditions which, in contempor-
ary times, cross different clinical disciplines, occupying neurological, neuropsycho-
logical, psychiatric, etc., domains in clinically relevant ways. Consequently, studies
exploring insight in patients with dementias are subject to the additional influences
of the specific conceptual frameworks of insight held by these different clinical dis-
ciplines. Secondly, and relating to this first issue, the clinical features themselves of
the dementias are also likely important contributors to the mixed results obtained in
studies exploring insight. Dementias are characterised by a range of diverse symptoms
and signs as a result of organic, psychiatric, psychological and functional changes.
Problems therefore can include various specific cognitive impairments (including
128
129 Insight in organic brain syndromes: insight into neurological states
memory), neurological deficits, affective changes, psychotic symptoms, personality

and/or behavioural disturbances, functional disabilities, and can also relate to the
experience of having the condition as a whole. These problems are different in kind
from each other and demand different ways of assessing insight. Studies exploring
insight into dementias therefore will be influenced by the problems that are chosen
as the ‘objects’ of insight assessment and, in turn, the latter will influence the particu-
lar concept of insight used by researchers. This theoretical point will be explored
more fully in Chapter 7. However, the issue here is that the different types of symp-
toms and signs characterising the dementias have resulted in a much wider range
of instruments assessing insight. Such instruments assess different aspects of insight
and will therefore contribute to the variability in study outcomes more than has
been the case with studies assessing insight in functional psychiatric disorders.
Particularly influential in studies exploring insight in dementia has been the
work on insight or awareness into neurological states. This chapter therefore pro-
vides an introduction to Chapter 5 and briefly examines such work concentrating on
the neurological and neuropsychological conceptualisations of insight. Chapter 5
follows on to review the empirical studies on insight in dementia and focuses par-
ticularly on the differences between various approaches to insight assessment and
their consequences on the aspect of insight elicited. Both chapters also review the
results of studies exploring insight in relation to different clinical variables.
4.2 Insight into neurological states
In contrast to the way in which interest in insight developed in general psychiatry

where attention was drawn to the phenomenon when patients were observed to show
some insight into their madness, interest in insight in relation to neurological states
developed from the opposite perspective. Namely, patients with marked neurological
abnormalities were, surprisingly, observed to show no insight or awareness into their
problems. Thus, since the late nineteenth century, the literature provides descrip-
tions of patients, seemingly oblivious to prominent and major neurological deficits,
who maintained their ‘unawareness’ and/or explicitly denied any disability in the
face of confrontative evidence to the contrary (e.g. Anton, 1899). Babinski (1914)
coined the term ‘anosognosia’ to refer to the unawareness or denial of hemiplegia
seen in patients following a stroke. The term has, since then, also been used to refer
to the unawareness displayed in patients with other neurological or neuropsycho-
logical syndromes. These include cortical blindness (Anton’s syndrome), aphasia
(Rubens & Garrett, 1991), hemiballismus (Roth, 1944), amnesic syndromes
(McGlynn & Schacter, 1989), dementia (Reed et al., 1993; Smith et al., 2000, see
below), tardive dyskinesia (Myslobodsky, 1986) and deficits seen following head
injury (Prigatano, 1991) and others.
Irrespective of the particular neurological/neuropsychological impairment

involved, the concept of anosognosia has, in contrast to the concept of insight in
general psychiatry, been consistent in generally referring to the more specific and
fairly narrow meaning of unawareness of a particular impairment. In a similar fash-
ion, a variety of different terms have been employed (and used interchangeably) in
the neurological/neuropsychological literature to refer to the concept, including,
e.g. loss of insight, unawareness, impaired awareness, impaired self-awareness or
impaired self-consciousness and denial. Nonetheless, the underlying concept has
been that of unawareness in its narrow sense, i.e. without any reference to more
wider judgements made by the subject. The one exception is in the use of the term
‘denial’ which has been used, in addition (though not consistently), in a psycho-
dynamic sense to refer to a concept where the subject is understood to have awareness
at some level (conscious or otherwise) but, for various reasons is unable or unwilling
to acknowledge this (Weinstein & Kahn, 1955). This distinction between unaware-
ness, as an inability to be aware of a deficit on neurological/neuropsychological
grounds, and denial, as an inability to be aware of a deficit on psychodynamic
or motivational grounds, is significant. It marks the division between two broad
lines of conceptualisation of loss of insight in neurological states that has been
evident in various forms since the late nineteenth century (McGlynn & Schacter,
1989; Prigatano & Schacter, 1991). And, both conceptualisations of unawareness
have been important in the empirical work on loss of insight in relation to demen-
tia (see below). In addition, the neurological or neuropsychological concept of
unawareness/anosognosia has been particularly influential in the more recent
empirical work on insight in psychoses seeking to associate poor insight with neuro-
psychological deficits and neuroanatomical substrates (see Chapter 3).
One question needs to be addressed before moving on to briefly look at some of
the models of unawareness in neurological states and related empirical work in this
area. This is the question concerning any difference between conceptualisation of
unawareness in the neurological/neuropsychological sense (excluding ‘denial’ in
the motivational sense) and unawareness or loss of insight in the general psychi-
atric sense of the concept. This is important for two reasons. First, research work
often extends ideas and results between different clinical areas, e.g. in studies mak-
ing analogies between anosognosia in neurology and loss of insight in psychiatry.
Second, it draws attention to the confusion that is often generated by the inter-
changeable use of various terms and will thus help to clarify the meaning of the
underlying concept.
Although literally meaning a lack of knowledge of disease, anosognosia or
unawareness in the neuropsychological sense refers to a much narrower notion of
knowledge than is usually understood by lack of insight or unawareness in the general
psychiatric sense. In the former, and likely as a result of its direct link to a specific
obvious impairment, the concept is much closer to the notion of a lack of conscious-
ness of a problem. In other words, it is lack of knowledge at the most basic level,
a loss of perception, which is invoked; that is, the ability to interpret apparent
changes in experienced sensory stimulation. The patient with anosognosia for
blindness cannot perceive he is blind. He is not making a correct interpretation of
his apparently disturbed sensory input. Similarly, the patient with anosognosia for
hemiplegia cannot perceive his disability, again he is not making a correct interpret-
ation of a neurologically apparent impairment of ability to move his limbs. The
concept is one of loss of perception, i.e. perception in the sense of the most primary
of knowledge involving direct interpretations of sensations. Clearly, as the concept
is extended to relate to a wider range of disabilities/neuropsychological impair-
ments, then these sensations become more complex structures incorporating internal
perceptions as well as sensations, e.g. in anosognosia for memory impairment. But
the core concept remains one of an impairment of perception or consciousness of
something. Within this framework, i.e. the inherent loss or impairment of basic
knowledge, there is not the scope for including other forms of judgements in the
way these are incorporated into the wider notion of lack of insight in relation to
psychiatric disorders.
It is important at this point to clarify another issue. Referring to the neurological
or neuropsychological conceptualisation of unawareness/loss of insight might give
the impression that there is only the one definition, only the one way of conceiving
loss of awareness in this field. In fact, that is far from the case. Here too, as in other
clinical areas, there are a multitude of definitions and models put forward in
attempts to describe and define a concept that remains complex and irreducible
except in very simplistic terms. The literature on consciousness or awareness is
extremely vast both in trying to explain normal mental and brain states as well as
pathological states. It encompasses perspectives from neurology, philosophy, psych-
ology, particularly cognitive neuropsychology, etc. and is a testament to the com-
plexity of the problem and the difficulties in trying to bring together phenomenal,
subjective qualities and neurological function/dysfunction into a common language
(Picton & Stuss, 1994). It is well beyond the scope of this chapter to review such work
and detailed and comprehensive texts can be found elsewhere (e.g. Brain, 1958;
Marcel & Bisiach, 1988; Milner & Rugg, 1992; Hameroff et al., 1996; Velmans, 1996;
Edelman, 2003). The essential point for the purposes of this chapter is that, accept-
ing the qualifications above, within the broad neurological/neuropsychological
framework, the core conception of impaired insight is that of impaired awareness or
consciousness. As such, it does not entail the secondary elaborations or judgements
that are intrinsic to the concept of insight in general psychiatry.
This narrower concept is reflected in the clinical phenomena of unawareness
that are elicited in neurological states and, as is described below, in the instruments
designed to assess these. Once again, it is necessary to provide some qualifications.

Unawareness in this narrower sense is generally conceived and elicited clinically as
a unitary phenomenon, i.e. patients are viewed as having or not having awareness
of their disability or aspects of their disability. (Some researchers argue that unaware-
ness, as applied in neurological states, is not a unitary phenomenon. However, it is
the term ‘unitary’ that is the source of confusion here rather than the way in which
unawareness is conceived and elicited.) Nevertheless, there have also been some
attempts to widen the notion and incorporate additional judgements to capture
more of the type of ‘knowledge’ patients have concerning their disabilities. For
example, Critchley (1953) refers to other forms of anosognosia and includes judge-
ments concerning ascribed ownership of paralysed limbs, their location in space,
their detachment from the body, names given to them, etc. Weinstein and Kahn
(1955) include similar judgements and, in addition, extend the concept by includ-
ing clinicians’ judgements of patients’ behaviours and incorporating clinical phe-
nomena, such as withdrawal, mood changes and inattention. Likewise, Cutting
(1978) brings together so-called ‘anosognosic phenomena’ with anosognosia in his
study examining clinical correlations with unawareness of hemiplegia. There, he
includes not just unawareness of the disability but also a range of attitudes towards
the disability (e.g. anosodiaphoria, misoplegia, personification, somatoparaphrenia).
Nevertheless, these sorts of elaborations on the part of the patient are intrinsic to
the abnormal awareness state itself, representing the primary pathological inter-
pretations of the abnormal perception. This can be likened to the way that some
psychotic patients might interpret delusionally what is happening to them. In this
sense, Weinstein and Kahn (1955) likewise refer to the ‘anosognosic delusion’.
However, this is not the same as the more involved judgements demanded of psy-
chiatric patients with respect to insight into their illness where such judgements
extend into relating abnormal experiences to the self and to their consequences to the
self. In other words, although further judgements are being assessed in these patients
with unawareness of hemiplegia, these judgements remain, in a sense, primary. They
cannot extend beyond the basic description of the specific experience. In part, this
is directly due to the perspective from which insight in neurological states is sought
and this will be discussed in detail in Chapters 7 and 8. In brief, however, by defin-
ition, it is not possible to demand judgements concerning the detailed consequences
of a problem if a problem is not actually experienced or perceived. Thus, the phe-
nomenon of awareness in neurological states remains focused on its narrow sense.
The recognition that unawareness/anosognosia is specific and selective, i.e. patients
could show awareness of some deficits (frequently mild ones) and yet be unaware
of others in the face of more extensive pathology (McGlynn & Schacter, 1989;
Bisiach & Geminiani, 1991; Jehkonen et al., 2000), or, show dissociation between
verbal denial and behavioural concomitants (Berti et al., 1998), has, however, helped
to broaden the notion and the instruments used to assess unawareness. For example,
in brain injury, attention has been paid to the different resulting deficits or disabil-
ities, e.g. behavioural problems, affective disorders, personality changes, etc. and
‘awareness’ has been examined in relation to these (Prigatano, 1991; Sherer, et al.,
1998; 2003b). Similarly, Blonder and Ranseen (1994) focused on examining
unawareness for cognitive and affective deficits rather than unawareness for hemi-
plegia in patients who had suffered strokes. Conceptualisation and evaluation of
unawareness in neurological states has therefore broadened in a number of ways
but, as is seen below, the core concept of unawareness remains narrow and rela-
tively circumscribed.
It is useful, for two main reasons, to briefly review some of the approaches assess-
ing impaired insight or unawareness in neurological states. Firstly, this helps to
illustrate more clearly the differences in conceptualisation of awareness/unawareness
between neurology/neuropsychology and general psychiatry. Secondly, the approaches
in this clinical area have been particularly influential in the methods developed for
exploring insight in patients with dementia.
4.2.1 Assessments of impaired insight/anosognosia in neurological states

Since the early case reports (e.g. Anton, 1899; Babinski, 1914; Roth, 1944; Redlich &
Dorsey, 1945; Stengel & Steele, 1946), studies in anosognosia have in recent years
become more systematic. Larger numbers of patients have been examined and
attempts have been made to evaluate the degree of anosognosia in structured ways
(Cutting, 1978; Bisiach et al., 1986; Prigatano et al., 1986; Starkstein et al., 1992;
1993a; Sherer et al., 1998a; 2003a). As with the various insight measures in
general psychiatry, a variety of assessment methods have been developed to study
unawareness in neurological states. Ratings range from simple dichotomous div-
isions, i.e. anosognosia is described as ‘present’ or ‘absent’ (Cutting, 1978; Hier et al.,
1983a, b; Levine et al., 1991), to multiple categorisations based on several point scales
(Bisiach et al., 1986; Cappa et al., 1987; Blonder & Ranseen, 1994). Such instruments
also vary from clinician-rated scales with set criteria in hemiplegia (Cutting, 1978;
Bisiach et al., 1986; Starkstein et al., 1992) to patient-rated deficits using question-
naires (Levine et al., 1991). More detailed and structured methods to assess unaware-
ness have been devised in relation to the multiple deficits sustained following head
injury. In this area in particular, discrepancy measures have been used to assess
awareness. In other words, patients’ awareness of their disabilities is defined,
empirically, as a function of the difference between theirs and their relatives’ percep-
tion of deficits as rated on structured questionnaires given to them both (Sunderland
et al., 1984; Oddy et al., 1985; Prigatano et al., 1986; Sherer et al., 1998). Dis-
crepancy measures have likewise been adopted in relation to amnesic syndromes
(Schacter, 1991; 1992) and, more recently, in dementia research (see Chapter 5).
The assumption underlying such methods is that relatives/carers or clinicians

are providing a ‘correct’ appraisal of the patients’ deficits against which patients’
perceptions are judged. However, it would seem plausible, as others have suggested
(McGlynn & Schacter, 1989), that relatives’ assessments of patient function are also
likely to be influenced by a number of factors which could lead them to overesti-
mate and/or to underestimate levels of impairment in patients. Such judgements
demanded of carers/relatives must depend on a variety of factors, not only on the
nature of the function in question, but also including type and frequency of con-
tact, the quality of relationship with the patient, individual observational capacity,
the effects of stress and affective disorders and psychological reactions such as
denial. In fact, with respect to unawareness of memory deficits, most work in this
area suggests that carers’ assessments of patients’ memory deficits correlate reason-
ably well with ‘objective’ tests of patients’ memory function (McGlone et al., 1990;
Feher et al., 1991; Koss et al., 1993). Nonetheless, some studies have indicated that
discrepancies are greater (and hence patients’ insight is poorer) when the burden of
care is perceived as greater by the carers (De Bettignies et al., 1990).
Much of the detailed and structured work in assessing impaired insight or
anosognosia in neurological states has been carried out in amnesic syndromes and
in traumatic brain injury. Foremost amongst the studies examining anosognosia in
amnesic syndromes has been the work by Schacter and colleagues (e.g. McGlynn &
Schacter, 1989; Schacter, 1991; 1992). To illustrate the type of assessment of aware-
ness developed in these areas it is useful to look at the comprehensive measure
described by Schacter (1991). Comprising of three main components, the first part
consists of a ‘General Self-Assessment Questionnaire’ in which patients rate on a
7-point scale the degree to which they experience difficulty with various aspects of
memory compared to before their illness. Relatives also complete this scale. The
second part consists of an ‘Everyday Memory Questionnaire’ in which a number of
hypothetical situations are described and patients are asked to rate the probability
that they would remember information in these situations (both currently and
before their illness) after delays of a minute, an hour, a day and a week. In addition,
they are asked to make similar ratings of their relatives’ abilities to remember in
these situations. Likewise, the relatives also complete this for themselves and the
patients. The last part consists of an ‘Item Recall Questionnaire’ in which patients
have to predict how many items they would remember (currently and prior to ill-
ness) if they were shown lists of 10 items (further subdivided into ‘easy’ and ‘diffi-
cult’ items), and are subsequently tested at each of the delays.
In the area of traumatic brain injury there have likewise been a number of com-
prehensive measures developed to assess impaired awareness of various deficits using
comparisons between patients’ ratings of deficits and ratings made by relatives or
clinicians or performance on specific tests (Prigatano et al., 1986; Anderson & Tranel,
1989; Allen & Ruff, 1990; Gasquoine & Gibbons, 1994; Sherer et al., 1998a). The
‘Patient Competency Rating Scale’ (Prigatano et al., 1986) evaluates patients’ aware-
ness of deficits on the basis of discrepancies between patients’ judgements of how
difficult they find tasks in certain areas (activities of daily living, cognitive func-
tioning, interpersonal functioning and emotional regulation) and the same judge-
ments made by relatives/clinicians. Ratings are scored on a Likert scale ranging
from 1 (can’t do) to 5 (can do with ease). Comparisons between patients’ judge-
ments and relatives or clinicians’ judgements determine the degree of unawareness
in patients by means of subtracting relatives/clinician scores from those derived
from patients. Similarly, Gasquoine and Gibbons (1994) report the use of Gasquoine’s
‘Self-awareness Questionnaire’ for patients with more severe head injury which also
compares patients and staff ratings in areas including awareness of: head injury,
physical impairment, communication difficulties, functional impairment and
sensory/cognitive impairment. The ‘Awareness Questionnaire’ developed by Sherer
et al. (1998a) likewise evaluates patients’ awareness of deficits on the basis of dis-
crepancies between patients’ judgements and relatives and/or clinician judgements.
However, the content of this questionnaire focuses on ratings made comparing
current and pre-injury functional abilities (cognitive area, behavioural/affective
area and motor/sensory area). Ratings are scored on a Likert scale ranging from
1 (much worse) to 5 (much better). Again, impaired awareness is evaluated by sub-
tracting scores of relatives’ or clinicians’ ratings from the patients’ self-ratings.
Similar approaches to evaluating insight have been taken in relation to patients
with dementia and will be reviewed in Chapter 5. However, what is evident from
the sorts of measures described above, is that the phenomenon of awareness or
unawareness elicited is, compared with the phenomenon elicited in general psych-
iatry, much sharper in definition and narrower in content. Patients are assumed to
either ‘know’ or ‘not know’ that they have a memory problem, or behavioural dif-
ficulty, or emotional changes, etc. Awareness is rated variously according to either
the perceived severity of the problem, or the frequency with which it is bother-
some, or the change from a previous state, or predicted ability on specific tests.
Irrespective of such ratings, the phenomenon is still focused on a unitary concept
of awareness in its narrow sense. This does not mean to say that the concept of
awareness is regarded as an all-or-none phenomenon and Schacter (1992) expli-
citly argues against such a point of view. Rather, it means that the qualitative differ-
ences in awareness are related directly and specifically to the tasks demanded of the
patients whether this is a judgement of severity, a comparison with previous func-
tion or with others, or prediction (and subsequent check) of performance on spe-
cific tests. In comparison, the conceptualisation of insight in general psychiatry has
necessitated different types of judgements on the part of the patient which have
determined a much wider, albeit less clearly defined phenomenon whose qualitative
aspects relate to a broader recognition of pathology and its consequences for

the individual.
4.2.2 Models underlying impaired insight/anosognosia in neurological states

One of the aims behind the refinement of instruments assessing awareness and carry-
ing out larger studies has been to explore possible mechanisms that might explain
unawareness or anosognosia in neurological states. Numerous theories have been
proposed and are comprehensively reviewed by McGlynn and Schacter (1989).
However, it is worthwhile to highlight some of the models developed as not only
have they contributed to the proposed explanations of insightlessness in relation to
dementia but they have also guided much of the recent empirical work on impaired
insight in relation to general psychiatry. Such theories can be roughly divided into
two broad groups, namely: (i) the neuroanatomical and the neuropsychological the-
ories, linked to the conceptualisation of awareness in its narrow sense of con-
sciousness as detailed above and (ii) the motivational, linked with the psychoanalytic
conceptualisations of awareness/insight.
4.2.2.1 Neuroanatomical and neuropsychological theories

Although arising from different perspectives, these two groups of theories/models
seeking to explain awareness and impaired awareness in neurological states may, for
the purposes here, be usefully reviewed together. This is because, firstly, they share the
common core conceptualisation of unawareness and, secondly, because of increas-
ing convergence between the postulated neuropsychological processes and specific
neuroanatomical structures (e.g. Stuss & Benson, 1986; Schacter, 1990; 1991).
A variety of neuroanatomical theories have been put forward as possible aetio-
logical bases to anosognosia. Diffuse generalised brain disease (Stengel & Steele,
1946) has generally been deemed insufficient to cause anosognosia, particularly,
since patients can be well orientated and have little evidence of general intellectual
impairment (Babinski, 1914; Roth, 1949; Cutting, 1978). Some specific support for
this view is also provided by Schacter (1991) from a neuropsychological perspective.
Using his detailed measure of awareness of memory deficits (see above), he described
a different pattern of results obtained from two densely amnesic patients. One patient,
whose amnesia was secondary to a ruptured aneurysm of the anterior communicat-
ing artery (ACAA rupture), showed poor awareness of memory deficits and over-
estimated his ability to recall items on the questionnaire as compared with his wife
who made more accurate predictions. In contrast, the other patient, whose amnesia
was secondary to herpes simplex encephalitis, showed much greater awareness of
her memory problems with ratings on the questionnaires consistent with her spouse’s
ratings and with her performance on testing. Both patients had equivalent severity
of memory deficits as measured by the tests and the intelligence quotient (IQ) of
the second patient was actually much lower than that of the first, suggesting that the
difference in awareness of deficits was unlikely to be due to generalised intellectual
impairment. In addition, the specificity of anosognosia for a particular deficit or
deficits, in the face of awareness of other impairments, also goes against the view
that generalised brain disease might underlie anosognosia.
More interest has thus focused on focal brain lesions as possibly underlying
anosognosia, e.g. thalamic (Roth, 1944; Redlich & Dorsey, 1945; Watson & Heilman,
1979) or striatal damage (Healton et al., 1982). Most focus, however, has been directed
at the right hemisphere, and particularly the parietal region has been implicated
(Hier et al., 1983a; Price & Mesulam, 1985; Bisiach et al., 1986; Goldberg & Barr,
1991; Rubens & Garrett, 1991; Bisiach & Geminiani, 1991; Starkstein et al., 1992;
Heilman et al., 1993). In general, though, findings have been inconclusive and
although anosognosia does seem to be more prevalent in patients with right hemi-
spheric lesions, it is also associated with left hemispheric damage (Cutting, 1978).
Experimental studies examining individual hemispheric function by inducing
temporary hemianaesthesia with intracarotid barbiturate injections have likewise
yielded mixed results. Some studies find anosognosia restricted to patients receiv-
ing right sided injections (and hence left hemiplegia) (Buchtel et al., 1992; Gilmore
et al., 1992) and others find no difference in the frequency of unawareness following
right and left sided injections (Kaplan et al., 1993; Dywan et al., 1995). Anosognosia/
unawareness in these experimental studies was elicited as a memory of the event
rather than elicited at the time of the hemiplegia developing which, as the researchers
pointed out, might influence the validity of the findings.
Numerous mechanisms subserving right hemisphere damage as the basis for
anosognosia have been suggested, including, e.g. disturbance of the body scheme
(Roth, 1944; Roth, 1949), ‘disconnection’ from the speech areas (Geschwind, 1965),
and personality disorder (Horton, 1976). However, there is little empirical evidence
provided for such mechanisms and, as others have argued, a body scheme disturbance
would not explain the unawareness manifest in relation to cognitive or behavioural
deficits or indeed to traumatic experiences (Weinstein & Kahn, 1955). Nor is there
evidence that patients are aware of deficits but are unable to express this awareness
(McGlynn & Schacter, 1989). The notion that unawareness develops as a result of
impaired position sense and sensory loss has also been refuted since researchers
found that neither somatosensory loss nor spatial neglect were sufficient to
account for anosognosia of hemiplegia in patients with right hemispheric strokes
(Bisiach et al., 1986; Levine et al., 1991; Berti et al., 1998).
Probably one of the most consistent findings has been the association between
anosognosia and frontal lobe dysfunction (McGlynn & Schacter, 1989; Goldberg &
Barr, 1991). And, much of cognitive neuropsychological work has likewise focused on
the frontal lobes as the central structures for self-monitoring and so-called executive
functioning (Stuss & Benson, 1986; Baddeley, 1987). An interesting model attempt-
ing to account for the different types of awareness in neurological deficits, pri-
marily related to memory, was proposed by Schacter (1990). This model, termed
DICE (dissociable interactions and conscious experience), postulated the existence of
a ‘conscious awareness system’ (CAS) which has direct links to individual ‘knowledge
modules’ such as lexical, conceptual, spatial, etc., as well as to an episodic memory
information system. Schacter suggested that whilst such modules/systems are in
constant or ongoing operation during normal mental and behavioural states, it
is only when the CAS is activated and when it interacts with such systems, that a
conscious experience of the particular information is obtained. Concentrating on
memory deficits, Schacter went on to discuss how damage at different levels in
such a system could explain both global and specific impairments of awareness. He
then put forward different levels of explanation within this model to account for
the various types of unawareness in both deficits and function (implicit memory, see
below). A first-order level of explanation, he said, would involve damage or impair-
ment within the CAS or with its individual connections. However, he favoured a
second-order level of explanation which would involve dysfunction at the level of
the knowledge modules themselves. Schacter then went on to postulate that the CAS
was a posterior system involving the inferio-parietal lobes, with connections to the
‘executive system’ situated in the frontal lobes (McGlynn & Schacter, 1989; Schacter,
1990; 1991). The model thus is an attempt to provide both a structural and func-
tional explanation of impairment in awareness and the dissociations in awareness
found in relation to different ‘modules’ or functions. In line with cognitive theory,
it assumes modularity of mental processes and hence the level of explanation is
directed at postulated individual cognitive systems and particularly at the proposed
connections between them. Models sharing similarity of approaches in terms of
integrating postulated cognitive processes and neuroanatomical structures can
be found also in Stuss and Benson (1986), Bisiach et al. (1986), Mesulam (1986),
Heilman (1991), and Prigatano (1991) amongst others. More recently, such mod-
els have been further elaborated and refined in attempts to capture the full hetero-
geneity found amongst anosognosic phenomena (e.g. Agnew & Morris, 1998).
Stuss and Benson (1986) make a conceptual distinction between self-awareness
and awareness of deficits in behavioural disorders such as neglect and aphasia. The
former is viewed as the highest psychological attribute of the frontal lobes, inter-
acting closely with organised function systems subserving various psychological
processes, e.g. attention, language and memory. Thus, damage to the frontal lobes
would result in a general disturbance of self-awareness, which, because of the varied
nature of the ‘self ’, in turn would lead to fractionation of disordered self-awareness
(Stuss, 1991). Awareness of deficits, on the other hand, is viewed as relating to the
specific functional systems themselves, such as language. Hence, impaired awareness
of deficit would involve impaired knowledge associated with the specific system
and would be related to dysfunction in posterior or basal brain regions. This view is
reiterated by others (Bisiach et al., 1986; Mesulam, 1986; Prigatano, 1991). Indeed,
Bisiach et al. (1986) emphasise this point, stating that anosognosia for a specific
deficit ‘betrays a disorder at the highest levels of organisation of that function. This
implies that monitoring of the internal working is not secured in the nervous sys-
tem by a general superordinate organ, but is decentralised and apportioned to the
different functional blocks to which it refers’ (p. 480, my emphasis). Thus, whilst
sharing some similarities with Schacter’s (1990) model in terms of endowing indi-
vidual cognitive or psychological process with intrinsic ‘monitoring’ functions, we
find here, in addition, a conceptual and an anatomical separation between impaired
awareness for a specific deficit and impaired awareness of the self. Stuss’s hier-
archical model of awareness develops this further and proposes four levels of aware-
ness linked to different anatomical substrates: (i) arousal, (ii) perceptual analysis of
incoming stimuli and engagement in complex motor activity, (iii) initiation and
self-monitoring of goal-directed behaviour and, (iv) self-awareness (Picton & Stuss,
1994; Clare, 2004). Thus, the conceptualisation of awareness at the highest level, in
theoretical terms becomes, in this neurological/neuropsychological frame, a much
broader concept, distinct from anosognosia, and, closer perhaps to the theoretical
notion of insight in general psychiatry.
Empirical evidence pointing to the contribution of frontal lobe dysfunction in the
development of anosognosia has come from a variety of sources. For example, it has
been observed that patients with the amnesic syndrome as a result of frontal lobe
impairment tend to be unaware of their memory deficit whereas patients with
amnesic syndromes as a result of temporal lobe damage tend to show some aware-
ness of their memory difficulties (McGlynn & Schacter, 1989; Schacter, 1991).
Nevertheless, there have also been reports of patients with amnesic syndrome and
frontal lobe dysfunction who had preserved awareness of memory deficits (Luria,
1976; Vilkki, 1985; Schacter, 1991). The prevalence of frontal lobe damage in patients
with unawareness of deficits following head injury (Prigatano, 1991) has, on the
other hand, supported a putative aetiological role for the frontal lobes in awareness
of dysfunction. With respect to cerebrovascular accidents, Starkstein et al. (1993b)
found that patients with anosognosia for hemiplegia (n 8) were significantly
poorer on neuropsychological tasks of frontal lobe function compared with
patients without anosognosia (n 8), though there were no differences on com-
puterised tomographical (CT) scan lesions. On the other hand, neuropsychologi-
cal tests did not discriminate between patients with and without awareness of
deficits following head injury (Prigatano, 1991). However, in this instance, patients
with reduced awareness of deficits had greater incidence of frontal and parietal lesions
on magnetic resonance imaging (MRI) or CT scans. Similar work correlating
unawareness with neuroimaging changes and frontal lobe neuropsychological tests

has been carried out in general psychiatry (and Chapter 3) and in dementia
research (and Chapter 5) and likewise yields mixed results.
4.2.2.2 Motivational theories

In contrast to the preceding neurological/neuropsychological approaches, others have
argued that the pathogenesis of anosognosia can be explained in terms of psycho-
logical processes or motivational factors within the patient. The main proponents
of these theories were Weinstein and Kahn (1955) who argued that anosognosia, or
denial of illness, was an adaptive response to avoid distress or a catastrophic reac-
tion to the recognition of disability. The authors were less concerned with the
actual mechanism of this process and referred, instead, to the dynamic approaches
of Schilder, Goldstein and Sandifer. They concentrated on providing a descriptive
account of patients’ behaviours which, they argued, could be interpreted as sym-
bolic representations of their ‘adaptation’ to disability. Weinstein and Kahn (1955)
did stress the point that such interpretations of behaviours (particularly in relation
to implicit denial) were very much dependent on the perspective of the observer
and his/her theoretical preconceptions. Basing their ideas on comprehensive obser-
vations of 104 patients with various forms of brain damage and anosognosia, they
distinguished between two kinds of behaviour indicative of denial. First, they
referred to explicit verbal denial which involved complete denial of illness, denial of
major disability, minimisation or attribution to some benign cause, projection of
disability outside of the self and temporal displacement of the disability. Second,
they described implicit denial which was suggested by behaviour such as with-
drawal, inattention, pain asymbolia, alteration in sexual behaviour, hallucinations
and mood changes. In both categories of denial, the authors contended, that it was
the symbolism behind either the words (explicit) or the behaviours (implicit) that
signified the adaptational nature of the behaviours and made ‘simple unawareness’ of
the disability less likely. Thus, for example, a patient complained about the ‘ham-
mering and the sawing on his head [but] still denied that he had had a craniotomy’
(Weinstein & Kahn, 1955, p. 69) or patients might misname objects related to their
illness and yet at the same time show they understood their use. One patient, express-
ing her denial through reduplication of her left arm, claimed that the extra paralysed
hand belonged to a close friend. Weinstein and Kahn (1955) suggested that this
expression of denial symbolised the close relationship between the two women.
Similarly, whilst patients were denying their illness, they nevertheless behaved like
other patients on the ward and accepted medication and medical management nor-
mally. Thus, argued Weinstein and Kahn (1955, p. 70), ‘it cannot be said that the
patient “forgets” or is “unaware” that he is ill but rather that he expresses his feel-
ings about it in a particular language’.
Whilst proposing psychological mechanisms, Weinstein and Kahn stressed,

nonetheless, the necessity for the presence of brain dysfunction itself in contributing
to the presence and expression of the multiple forms of denial or anosognosia. They
did not claim that the brain dysfunction caused the denial but argued that the level
of brain function determined the ‘integration of the pattern in which the denial is
expressed’. In other words, it was the alteration in the brain function that provided the
environment or ‘milieu’ in which the denial could be expressed but the latter itself was
determined by individual psychological factors. Consequently, they proposed, it was
not the localisation of the lesion or the type of disability itself that were specifically
related to the presence or type of denial shown by the patient although they did stipu-
late that deeper brain structures had to be affected. Rather, it was the individual’s
personality and previous experience that determined the type of denial manifested,
i.e.‘the symbolic modalities in which he habitually expressed his motivations’ (p. 97).
The non-specificity of the brain lesion in this regard also helped to explain why such
a range of disabilities or dysfunctions might be denied, not just hemiplegia or blind-
ness but the fact of having an operation or some distressing family or social event.
Anosognosia or denial using this model is thus conceived as developing within a
dynamic interplay of brain and personality motivational factors though the specific
mechanisms remain unclear. Weinstein (1991) later stated,‘… The existence and form
of denial/anosognosia are determined by the location and rate of development of the
brain lesion, the situation in which the denial is elicited, the type of disability, and the
way the patient perceives its meaning on the basis of his past experience’ (p. 254).
On the basis of questionnaires and interviews exploring individual/personality
factors with relatives of patients showing denial, Weinstein and Kahn (1955) sug-
gested that a particular personality type predisposed to the development of denial.
Such patients, they claimed, premorbidly considered illness as a weakness or failure
and were strongly concerned about the opinions of others and had strong drives to
do well and to succeed. Subsequently, Weinstein et al. (1994) attempted to capture
such personality traits empirically by means of their Denial Personality Ratings in
their research on denial or anosognosia in dementia. On the other hand, personality
factors, as assessed by the Eysenck Personality Questionnaire (scales for measuring
extroversion, neuroticism, psychoticism and a lie scale), were not found to distin-
guish between patients who denied (n 20) and those who did not deny (n 10)
their hemiplegia following acute stroke in the study by Small and Ellis (1996). The
same study did suggest, however, that whilst relatives did not class patients with
denial as being perfectionists, nevertheless, the patients with denial rated them-
selves as having difficulty in admitting to illness in general compared with patients
who did not show denial.
As McGlynn and Schacter (1989) point out, there are a number of problems
with viewing anosognosia or unawareness of deficits predominantly in terms of
motivational or psychological processes. For example, it is difficult to account for

the specificity of anosognosia seen frequently in neurological states. Nor, if uncon-
scious psychological mechanisms are postulated, should the site of the lesion make
much difference. Likewise, the time course of anosognosia is often inconsistent with
the views on onset and course of motivated denial. Emphasising these difficulties,
Lewis (1991) distinguished between psychogenic and neurogenic denial. However,
she stressed the importance of interaction of both psychological and neurological
factors in the overall production of denial.
4.2.3 Empirical studies of impaired insight in relation to neurological states

Much of the empirical work on impaired insight in neurological states has, in fact,
been focused on looking for associations between anosognosia and specific brain
lesions (as described above). However, there have also been other areas of interest. A
few studies have examined the relationship between impaired insight/anosognosia
and different neurological impairments (e.g. hemiplegia, hemianopia, amnesia) and
clinical variables such as severity of impairment or lesion, presence of emotional
problems or neuropsychological impairment. These have been comprehensively
reviewed elsewhere (Vuilleumier, 2000). As in other clinical areas overall results
are mixed and inconsistent. Importantly, however, there is some suggestion that
anosognosia is a poor prognostic factor for functional recovery following stroke
(Gialanella & Mattioli, 1992; Pedersen et al., 1996; Appelros et al., 2002).
Of particular clinical relevance has been the more recent work exploring the
likely importance of awareness or degrees of insight in traumatic brain injury, par-
ticularly from the perspective of rehabilitation. Earlier studies had reported a high
prevalence of impaired awareness of behavioural/cognitive problems amongst
patients following traumatic brain injury (Sunderland et al., 1984; Oddy et al.,
1985). This has been recognised as a significant factor complicating rehabilitation
and influencing clinical outcome (Prigatano, 1991; Gasquoine & Gibbons, 1994;
Sherer et al., 1998b). Further studies have attempted to characterise such impaired
awareness in order to determine its predictive value and also to enable rehabilita-
tion strategies to be targeted appropriately. So far, the few studies that have been
carried out in this regard have also yielded inconsistent results though they await
replication (Sherer et al., 1998b).
Studies examining the relationship between various clinical variables and the pres-
ence of impaired awareness yield mixed results. For example, some studies suggest
that more severe head injury is associated with poorer awareness of disability
(Levin et al., 1987) while others find no such association (Anderson & Tranel,
1989; Gasquoine, 1992; Sherer et al., 2003b). Similarly, some studies find an associ-
ation between level of cognitive impairment and level of awareness of disability
(Anderson & Tranel, 1989) and others find no such association (Prigatano & Altman,
1990; Prigatano et al., 1997). Some studies suggest that patients with greater
awareness of their disabilities have more emotional distress or depression
(Gasquoine, 1992; Godfrey et al., 1993; Wallace & Bogner, 2000). A more consistent
finding reports patients, following traumatic brain injury, as being more aware of
their physical deficits than of their non-physical, i.e. emotional and cognitive prob-
lems (Gasquoine, 1992; Gasquoine & Gibbons, 1994; Prigatano, 1996; Sherer et al.,
1998b; Hart et al., 2004). Overall, however, there have been too few studies to
conclude very much about the relationship between awareness of disability and
characteristics of the traumatic head injury. Moreover, the studies are diverse
methodologically, employing different measures of evaluating awareness, of sever-
ity of head injury, of emotional and cognitive states, etc.
In regard to patient awareness and rehabilitation following head injury, Sherer
et al. (2003b) report that early self-awareness is associated with older age at admis-
sion to rehabilitation and with prediction of employability at discharge from inpa-
tient rehabilitation (Sherer et al., 2003b). Their study, examining 129 patients with
traumatic brain injury, used the Awareness Questionnaire (Sherer et al., 1998a).
Whilst needing replication, it highlights the need for early assessment of patients’
awareness in the prediction of various functional activities and stresses the need
for further research to determine if treatment programmes directed at impaired
awareness might help functional outcomes.
A number of interesting approaches to characterising impaired awareness have
been put forward with a view to devising treatment programmes directed at impaired
awareness following traumatic brain injury. For example, based on different time
frames, Crosson et al. (1989) proposed a nested conceptualisation of awareness dif-
ferentiating between awareness of the problem generally (intellectual awareness),
awareness of the problem when manifest (emergent awareness) and awareness of
the problem in advance (anticipatory awareness). The type of deficit in awareness
shown by the patient then determined the particular compensatory strategy that
could be employed in rehabilitation work. On the other hand, Allen and Ruff
(1990) suggested that patients’ assessment of their cognitive abilities was guided
by three processes, namely awareness (the ability to recognise problems), appraisal
(the ability to compare the current state with previous functioning) and disclosure
(the willingness to articulate or report their understanding of their state to others).
For rehabilitation purposes it would thus be important for the clinician to assess
the patient from the perspective of each of these processes.
A different approach, but sharing some similarities with the above, was taken by
Langer and Padrone (1992) who described a tripartite model for conceptualising
impaired awareness after brain injury attempting to integrate both the neurological/
neuropsychological and the motivational concepts of awareness. Thus, they identi-
fied three components of awareness, namely, information (actually having the right
information in order to be able to be aware of it), implication (to be aware of impli-

cations of the information) and integration (having the information and knowing
the implications of this and behaving accordingly). Patients could have impairments
of any of these components which would then manifest as deficits in awareness.
For example, if they did not have the right information, then they would appear
to be unaware of the problem. If they had the information but could not see the
implications then they would also show impaired awareness. And if they had the
information and were potentially aware of its implications and yet behaved as if
they did not have it, then they would be denying their problems. Again, depending
on the level of impairment, treatment in terms of rehabilitation could be tailored
accordingly. Such approaches await further empirical testing and may have import-
ant therapeutic implications. Moreover, they are indicative of a further broadening
of the concept of awareness in this area as different sorts of judgements are being
incorporated in the structure of awareness as a whole.
4.3 Impaired awareness of function in neurological states
Anosognosia has been defined as unawareness of deficit but, in relation to neuro-

logical states, much interest has been directed, in addition, at unawareness or impaired
insight of function or knowledge. Thus, akin to the clinical accounts produced in
the late nineteenth century on patients with anosognosia in neurological impair-
ments, observations were recorded of other patients who appeared to show no overt
awareness or insight into their abilities or preserved function. Korsakoff (1889), in his
original descriptions of the amnestic syndrome, was particularly interested in this
aspect of insight. Thus, whilst commenting on the lack of concern (rather than lack
of awareness) shown by patients about their memory impairment, he was struck
also by the level of their unconscious knowledge. In other words, patients did not
seem to be aware that they knew certain things and, on questioning, would specifically
deny that this was the case. Thus, Korsakoff noted that whilst such patients might
not recognise him despite repeated daily contact, they nevertheless recognised that
he was a doctor. Furthermore, months or even years after their illnesses, patients
could recollect conversations or events occurring during their illness of which they
had no awareness at the time. Consequently, he postulated, memory traces must be
laid down at an unconscious level. In addition, Korsakoff observed that the uncon-
scious knowledge was evident to differing extents in relation to different aspects of
memory. For example, patients would show pleasant and sympathetic behaviour
towards certain individuals and events but hostile or unsympathetic behaviour
towards others. Therefore, he believed, this suggested that patients preserved
unconsciously affective responses in the face of a lack of conscious recollection of the
people/situations evoking such responses (Korsakoff, 1889).
The theoretical notion of unconscious knowledge or memory in the ‘healthy’

subject, i.e. knowledge or memory of which an individual is not consciously/overtly
aware can be traced, in various forms, back to the seventeenth century to the writ-
ings of Descartes, Leibniz and others (for a historical review see Schacter, 1987). In
the context of a general interest in unconscious mental processes in the nineteenth
century, a number of physiologists highlighted the importance of the uncon-
sciousness in the constitution of memory itself (Hering, 1870/1920; Butler,
1880/1920). For example, the Viennese physiologist Hering (1870/1920, p. 72),
emphasised that memory, ‘… whose results, it is true, fall, as regards one part of
them, into the domain of consciousness, while another part and not less essential
part escapes unperceived as purely material processes’. Since such early theoretical
observations in relation to normal function and anecdotal reports in various
clinical states (e.g. Korsakoff, 1889; Janet, 1904), the concept of ‘unconscious
knowledge’ in various guises has only developed as the focus of systematic research
in cognitive (and to some extent behaviourist) psychology since the middle of the
twentieth century (Reber, 1993; Schacter, 1995).
In general terms, two parallel research programmes appeared to develop inde-
pendently, one focusing on ‘unconscious learning’ or implicit learning (Reber,
1993), and the other focusing on ‘unconscious memory’, later termed ‘memory
without awareness’ (Jacoby & Witherspoon, 1982) or ‘implicit memory’ (Graf &
Schacter, 1985). Some efforts have been made to bring together and integrate the
cognitive models and approaches used in each of these areas (Reber, 1993). More
recently, these approaches have also been applied to the area of metacognition
(Metcalfe & Shimamura, 1994; Reder, 1996, see also Chapter 2). The common
issues have revolved around the idea that much of normal mental processing, be it
learning, perceiving, remembering, etc. seems to take place without the individual
being consciously or explicitly aware of these. Cognitive psychological research has
focused on developing different tests to explore the contribution or otherwise of
consciousness to such mental processes. Indeed much of the terminology referring
to unconscious or implicit mental processes in these contexts has to be viewed as
reflecting subjects’ responses to, and results from, specific neuropsychological tests
rather than necessarily representing distinct mental phenomena. In other words, it
is important when considering this research to bear in mind some of the crucial
assumptions on which studies are based. Most importantly, there is firstly the
assumption concerning the putative divisions of the mind or mental functions as
conceived in neuropsychological models both in terms of the ‘modules’ of cogni-
tion and their interrelationships and their contents of ‘cognition’. Secondly, there is
the assumption that the specific tests are ‘pure’ in the sense that they can actually
distinguish between conscious/explicit processing and unconscious/implicit mental
processing, and, in fact, this has been challenged (e.g. Jacoby & Kelley, 1992; Rugg,
1995) with the consequence that there is continued refining of such tests and mod-
els. Thus, in regards to implicit memory in this particular neuropsychological con-
text, the term has been defined in a specific technical sense: ‘Implicit memory is
revealed when performance on a task is facilitated in the absence of conscious rec-
ollection; explicit memory is revealed when performance on a task requires con-
scious recollection of previous experiences’ (Graf & Schacter, 1985, p. 501).
The neuropsychological tasks used to elicit implicit memory have involved primar-
ily repetition priming tests and skill-learning tasks (Schacter, 1987). Much work
has been carried out in researching implicit memory in healthy subjects but, inter-
estingly, implicit memory has also been demonstrated in patients with amnesic
syndromes, who are thus able, for example, to show effects of priming on memory
tests without recalling the priming itself (Warrington & Weiskrantz, 1968; 1974;
1982; Cermak et al., 1985; Shimamura, 1986; McAndrews et al., 1987; Schacter,
1991). In other words, dissociations between implicit and explicit memory can be
demonstrated suggesting that these may represent different aspects of memory
which may be disturbed independently. Furthermore, various impairments in
implicit memory itself and further dissociations between different types of implicit
memory tasks used (e.g. verbal/non-verbal material, words/non-words, patterns,
perceptual, auditory, etc.) have been found in patients with amnesic syndromes
indicating that dysfunction can occur at specific (task-determined) levels (Schacter,
1995). For example, it was found that while priming effects for common words and
idioms in amnesic patients is comparable to control subjects, amnesic patients
seem to fail to show priming effects for non-words (Cermak et al., 1985). Other
studies have found preserved implicit memory in amnesic patients using skill-
learning tasks. Patients were taught to learn and retain new skills such as computer
training and yet they remained ‘unaware’ of having such training or skills (Glisky
et al., 1986). Clearly, demonstration of the presence of implicit memory as well as
of different types of impaired implicit memory in patients with amnesic syndromes
(and patients with dementia) has been dependent on such very specific neuro-
psychological tasks.
The question that remains, however, concerns the structure of awareness and its
relationship to other mental structures. And how can the impairments in different
aspects of awareness be explained and understood? As far as neuropsychological
approaches are concerned, implicit memory or knowledge has tended to be addressed
predominantly from the perspective of the mental functions themselves rather
than from the perspective of an awareness or consciousness system although the
latter has been postulated in an abstract form in relation to the mental functions
(e.g. Schacter, 1990). For example, explanations for implicit memory, rather than
being directed at the awareness aspect of the concept, have focused on memory
itself in terms of how it is retrieved, the contribution of context and the possibility
of multiple as opposed to single memory systems. This has led to some researchers
suggesting that the notion of implicit memory is redundant outside the specific con-
straints of neuropsychology testing (Willingham & Preuss, 1995).
Impaired insight/awareness of knowledge or function has been described also in
other neurological syndromes. Most striking perhaps is the example of ‘blindsight’,
where there is ‘visual capacity in a field defect in the absence of acknowledged
awareness’ (Weiskrantz, 1990, p. 166). The patient described by Weiskrantz had a
left hemianopia following excision of a malformation within the occipital lobe, yet,
was able to perform visual tasks in his left field at a level that was significantly
higher than chance. At the same time, he appeared unaware of his ability to per-
form at such a level, expressing surprise when informed he had ‘guessed’ correctly.
Likewise, patients with visual neglect responded to priming tasks despite overt
denial of the presence of stimuli in their neglected field, again indicating the pres-
ence of some form of unconscious or implicit appraisal (Berti & Rizzolatti, 1992).
Similarly, in prosopagnosia, where patients are unable to recognise familiar faces
overtly, implicit recognition has nevertheless been suggested by the fact that such
patients show increased autonomic responses (skin conductance responses, respir-
ation rate/depth) on testing with familiar faces (Bauer, 1984; Tranel & Damasio,
1988; Benton & Tranel, 1993).
A number of mechanisms have been proposed to explain such phenomena, includ-
ing, e.g. damage to one of two postulated separate channels (holding different
types of retinal information) involved in visual perception (Perenin & Jeannerod,
1975, 1978; Perenin et al., 1980). A different type of ‘neural disconnection’ has been
put forward by Weiskrantz (1988; 1990) who suggested that there was a split between
the capacity to perceive and an awareness or commentary on this, thus implying dam-
age to a parallel ‘monitoring’ system. Another ‘disconnection’ hypothesis, at a more
neuroanatomical level, based on damage to selective neural paths from the visual
system to the limbic systems, was proposed by Bauer (1984, p. 466) in relation to
prosopagnosia. He suggested that in prosopagnosia there is damage to the ‘ventral’
path which, following Bear (1983), is a ‘modality-specific “foveal system that recog-
nises objects [faces] by multiple attributes” and mediates modality-specific orient-
ing and stimulus-response learning’. The ‘dorsal’ path, on the other hand, which
carries emotional tone or ‘relevance’ for the face, is intact, and hence, there is the
observed autonomic arousal on presentation of familiar faces (Bauer, 1984; 1993).
As already mentioned, Schacter (1990) in relation to the amnesic syndromes, includ-
ing implicit or unconscious awareness of memory, suggested a mechanism involv-
ing impairment to the memory system itself rather than invoking damage at the
level of an awareness or monitoring system.
In these and other instances, e.g. in blindtouch (Paillard et al., 1983), the ‘object’
of awareness or insight relates to function or knowledge. Clearly, this contrasts with
the previously discussed research on anosognosia or impaired insight, where the

‘object’ of awareness related to deficits or impairment in function. Likewise, insight
in general psychiatric disorders and dementias has focused predominantly on path-
ology, on abnormalities or impairments as a result of illness rather than on func-
tioning or abilities (though for recent studies on implicit memory in dementia, see
Chapter 5). Whilst this distinction has been made at a definitional level and differ-
ent mechanisms have been postulated, this remains a relatively unexplored area at
a conceptual level. In other words, what is the relationship between these types
of impaired awareness, and how do they relate within the notion of insight as
a whole? If there is implicit awareness or knowledge with respect to capacity/
function, is there also implicit awareness with respect to deficits?
Furthermore, closer examination of the implicit/covert awareness exhibited in
the different clinical situations suggests that perhaps these phenomena may not
necessarily be of the same type. For example, in patients with prosopagnosia, their
covert recognition of familiar faces is demonstrated by their autonomic responses
in the face of their overt inability to recognise these faces. Similarly, amnesic
patients demonstrate implicit memory through their ability to use knowledge or
skills they have learnt previously, without recognising that this is the case. With
blindsight, however, it has been shown that awareness of the ability to discriminate
visual objects varies according to the presented stimulus (location, distance,
salience). In addition, even though the patients may say they are ‘guessing’, it
appears that they are aware of a ‘feeling’ or different perception: ‘wave-like impres-
sion’ (Weiskrantz, 1990, p. 167). A similar phenomenon was described by Paillard
et al. (1983) in their patient with deafferentiation in her right hand, who was able
to discriminate tactile stimulation, though was unable to experience the stimula-
tion as a ‘touch’ sensation. The question then has to be posed as to whether the
observed phenomenon is really impaired awareness, or whether the patient is
describing (or having difficulty describing) a qualitatively different perceptual
experience which guides the discriminating capacity. In other words, it might be
that in this case, ‘awareness’ is intact, but appears impaired because of the difficul-
ties in linking a ‘foreign’ perceptual experience with tasks dependent on a ‘normal’
visual/tactile experience.
Some mention should also be made of some related research examining aware-
ness that falls perhaps in a level between the above implicit type of awareness or
knowledge and the previously considered conscious or explicit awareness/knowledge.
The ‘feeling of knowing’ phenomenon has been studied in the field of metacognition
and used as a test of ‘metamemory’, i.e. ‘knowledge about one’s memory capability
and knowledge about strategies that can aid memory’ (Shimamura & Squire, 1986,
p. 452). Patients are asked to judge, on the basis of a ‘feeling of knowing’, whether they
would ‘recognise’ the correct answers to questions even if they did not know the
answers spontaneously. Recognition of things on the basis of a ‘feeling of knowing’

has been conceived in cognitive neuropsychology as a form of awareness though
viewed from a different perspective and couched in different terms. Indeed,
‘metamemory’ is conceptualised as an independent ‘cognitive’ system which can
become impaired separately from memory itself (Shimamura & Squire, 1986;
Shimamura, 1994). Interestingly, the ‘feeling of knowing’ is not considered as con-
stituting an aspect of insight in Gestalt cognitive psychological terms (Metcalfe,
1986b, see Chapter 2) where again, the specialised perspectives of that discipline
preclude a broader notion.
Finally, a brief reference has to be made to experimental situations where the
notion of awareness, albeit in a somewhat different sense, has also been raised.
Penfield (1975) described ‘experiential’ phenomena evoked upon stimulation of
the temporal cortex in patients with epilepsy. Patients reported complex hallucin-
ations, illusions, memory flashbacks, etc. accompanied by a sense of reality of the
experience, though, at the same time, were aware of what was happening in the oper-
ating room. Penfield suggested that this double awareness was possible because of
the independence of the ‘mind’ from brain mechanisms. In other words, ‘although
the content of consciousness depends in large measure on neuronal activity, aware-
ness itself does not’ (Penfield, 1975, p. 55). In similar studies, Gloor et al. (1982),
found that it was necessary to stimulate the limbic structures in order to confer the
sense of ‘experiential immediacy’ to the evoked phenomena. They thus suggested
that ‘limbic activity may be essential for bringing to a conscious level percepts
elaborated by the temporal neocortex’ (p. 140). They further postulated that
this was achieved by the limbic structures through the attachment of affective/
motivational significance to the percept. In other words, and sharing corollaries with
the model proposed by Bauer to explain covert recognition of faces in prosopagnosia,
in order for an object to be consciously perceived, there has to be an affective
dimension to the perceiving.
4.4 Conclusion
The study of insight in neurological states has developed from two main perspec-
tives. First, has been the focus on patients’ apparent unawareness of major neuro-
logical disability (anosognosia). Second, has been the exploration of patients’
apparent unawareness of preserved function (implicit knowledge). In both areas of
study, unawareness has been conceptualised in a much narrower sense than lack of
awareness or insight in general psychiatry. The narrower conception of awareness
is reflected both in the types of empirical measures designed to assess awareness
clinically and in the neuroanatomical and neuropsychological models devised to
explain specific impairments in awareness.
The ‘neurological’ approach is essential to consider for several reasons. First, as

was seen in Chapter 3, recent studies exploring insight in general psychiatry are
based on analogies of impairment of insight with anosognosia. Second, clarifica-
tion of the concept of ‘neurological’ unawareness helps to determine differences and
commonalities in the meanings/models of ‘insight’ used in different studies, par-
ticularly where related terms are used interchangeably (see Part II). Third, the ‘neuro-
logical’ approach has been particularly influential in the exploration of insight in
the dementias. This is now examined in Chapter 5.
5
Insight in organic brain syndromes: insight

into dementia
Empirical studies exploring patients’ insight or awareness into dementia have been
notably prolific, particularly over the past 15 years. In contrast to the relatively con-
sistent approach taken to the study of insight in relation to neurological states,
studies examining insight in the dementias are striking in the range of different
approaches taken (Kaszniak & Christenson, 1996). As was suggested in the preced-
ing chapter, a likely explanation for the differences seen may be in part due to the
particular clinical nature of dementias themselves as well as their position in occu-
pying neurological, psychological and psychiatric professional domains. It is per-
haps not surprising that, much in the same way as research on insight in functional
psychiatric syndromes, outcomes from studies exploring patients’ insight into
dementia and clinical variables (e.g. stage of dementia, severity of dementia, level
of cognitive impairment, etc.) have been particularly mixed and inconsistent
(Marková & Berrios, 2000).
This chapter reviews the empirical studies exploring insight in dementia and
focuses on the specific conceptual issues arising from research in this area. First,
differences in definitions and underlying concepts are explored. Then, the varied
approaches taken to assess insight empirically are examined and related to the
likely clinical aspects of insight elicited. Lastly, the results of studies exploring the
relationship between patients’ insight, and various clinical and socio-demographic
variables are reviewed.
5.1 The meaning of insight in relation to dementia
The first question relates to the meaning of insight in dementia. What is meant by
‘insight’ in dementia? Does it share similarities with the other notions of insight
discussed so far, e.g. insight in psychosis or in neurological states? Reviewing the
literature on insight in dementia, however, shows that there are some difficulties in
answering this question. These difficulties can be identified at various levels. First
of all, it is apparent that there are differences in both the terms used and concepts
involved between the various empirical studies. Secondly, there are striking vari-
ations between studies in terms of which features of dementia are the focus of
151
insight evaluation, highlighting the importance of the relational aspects of insight

in determining its meaning. Thirdly, a wide range of different methods of assessing
insight have been used by researchers, carrying implications for the meaning of
insight elicited in empirical studies. Before considering the results of empirical
work on insight in dementia, it is necessary to examine these particular areas in
more detail.
5.1.1 Terms and concepts

A number of related terms are used in studies aiming to explore the degree of
patients’ understanding or recognition of problems in relation to dementia. Such
terms include ‘loss/lack of insight’ (De Bettignies et al., 1990; Mangone et al., 1991;
McDaniel et al., 1995), ‘lack/impairment of awareness’ or ‘unawareness’ (Anderson &
Tranel, 1989; McGlynn & Kaszniak, 1991a, b; Green et al., 1993; Vasterling et al.,
1997; Wagner et al., 1997, Clare et al., 2002), ‘anosognosia’ (Feher et al., 1991; Reed
et al., 1993; Michon et al., 1994; Migliorelli et al., 1995; Smith C.A. et al., 2000),
‘denial’ (Sevush & Leve, 1993; Weinstein et al., 1994; Deckel & Morrison, 1996),
‘impaired self-awareness’ (Loebel et al., 1990; Kaszniak & Christenson, 1996), ‘self-
monitoring/metamemory problem/self-assessment’ (Correa et al., 1996; Theml &
Romero, 2001) and ‘self-consciousness’ (Gil et al., 2001). This immediately raises a
number of questions. First of all, do these various terms refer to a common under-
lying concept or do they perhaps reflect quite different concepts? Secondly, are
these terms and concepts used in a consistent way within the research in this area?
Thirdly, if there are differences in meanings, are these important from a clinical
and/or research point of view?
At a theoretical level, the various terms clearly do imply different concepts. They
are different with respect to their origins, i.e. arising in various historical contexts
and within the specific frameworks relating to different professional disciplines, and
consequently, they determine structures that are different from one another. We
have already seen how the concept of insight in relation to mental illness developed,
in the context of changing views around individuality, subjectivity, etc., as well as
around mental illness itself. Within general psychiatry, the meaning of insight has
thus retained a relatively broad structure. This incorporates individuals’ under-
standing of their pathological experiences not only in terms of the latter’s manifest-
ation but also including judgements concerning the effects of such experiences,
psychologically, socially and functionally. Different has been the conceptualisation
of denial in psychoanalytic terms where a broader structure still has developed in
the context of a deeper view of self-knowledge and the interaction of conscious
and unconscious mental processes. Different again has been the development of
anosognosia as a concept, emerging almost independently as a phenomenon, in the
face of an individual’s dramatic lack of understanding or recognition of a significant
153 Insight in organic brain syndromes: insight into dementia
neurological deficit. And, linked so inherently to the neurological or neuropsycho-

logical impairment, the meaning within the neurology and neuropsychology fields
has consequently been much narrower in structure. Similarly, the newer concepts
of self-monitoring, and metamemory or metacognitive processes are products of
approaches taken in cognitive and Gestalt neuropsychology and framed in the spe-
cific technical language that has developed with the increasing specialisation of
these disciplines. The meanings invoked by those terms thus relate to the concepts
bound by different categories (e.g. information processing) and they therefore
determine different structures. A further issue that complicates the meaning of con-
cepts referred to by such technical terms concerns the additional inclusion of the
lay usage of the terms. This is particularly relevant in relation to the use of the term
‘denial’. In the psychological conceptualisation, as described above, it has a two-
fold meaning in that it refers firstly to an unawareness albeit implying awareness at
some (deeper or unconscious) level and secondly it incorporates a psychological
mechanism underlying and explaining the unawareness. Whilst the term ‘denial’
has been used in a number of different ways (Beaumont, 1999), generally, in lay
language, it is used descriptively to refer simply to the refusal made by an individ-
ual to admit to an overt dysfunction or experience. In this latter sense, the mean-
ing is clearly quite different in structure from the technical concept.
In practice, however, such conceptual distinctions are generally not explicated.
Most studies examining insight or awareness in dementia tend not to define speci-
fically the particular concept involved and, moreover, the different terms are fre-
quently used interchangeably (e.g. Feher et al., 1991; Verhey et al., 1993; McDaniel
et al., 1995; Starkstein et al., 1996; Smith C.A. et al., 2000). This makes it sometimes
difficult to identify the particular sense of the underlying intended concept.
McGlynn and Schacter (1989) in their review of this area, in general neuropsycho-
logical impairments, highlight such difficulties and explicitly use the terms ‘anosog-
nosia’, ‘unawareness of deficit’ and ‘loss of insight’ interchangeably. However, they
make it clear that they are using these terms to refer to the underlying concept of
unawareness in the narrow sense, and they specifically distinguish this concept from
‘motivated denial’ which they view as a separate phenomenon. In other words, they
apply the broad distinction, that had emerged from research in this area in neuro-
logical states (Chapter 4), between the neurological/neuropsychological concepts
of unawareness/anosognosia on the one hand, and the psychological concept of
denial on the other.
With respect to studies in dementia, where there are explicit distinctions between
various terms (and concepts), a further problem arises because the grounds on
which distinctions are made, and meanings attributed to the terms, are different
amongst researchers. For example, some researchers make a similar conceptual
distinction, as described above (McGlynn & Schacter, 1989), using ‘unawareness’
and ‘anosognosia’ interchangeably (and in the neuropsychological sense) but

distinguishing this categorically from ‘denial’ (Reed et al., 1993; Kotler-Cope &
Camp, 1995). Others use all the terms (unawareness, denial, loss of insight and
anosognosia) interchangeably, generally referring to a fairly narrow definition,
focusing on the non-recognition (or non-acknowledgement) by the patient of cog-
nitive or other impairments (Feher et al., 1991; Sevush & Leve, 1993; Verhey et al.,
1993). Other meanings are not as clear. Reisberg et al. (1985), in one of the earliest
systematic studies of awareness in patients with dementia, using the term ‘anosog-
nosia’ (or ‘lack of recognition of disease’), seem to refer to a broader concept incorp-
orating both denial and lack of insight. They suggest that anosognosia in patients
with dementia may be ‘a product of decreased insight, itself an invariable symptom
of the illness process … (or) the product of denial or other so-called “psychological
mechanisms of defense”’ (Reisberg et al., 1985, p. 39). In other words, within their
conception, ‘anosognosia’ is a descriptive term for the phenomenon observed when
patients do not recognise their dementia. In contrast, loss of insight and denial are
viewed as the mechanisms responsible, the former in terms of an organic process
intrinsic to the disease itself and the latter in terms of a psychological reaction.
Interestingly, Deckel and Morrison (1996), in their study on anosognosia in
patients with Huntington’s disease, conceive the relationship between denial and
anosognosia somewhat differently. They refer to aspects of denial as representing
an anosognosia. In other words, they view anosognosia as the neurologically deter-
mined process of unawareness. Weinstein et al. (1994), on the other hand, use the
terms ‘anosognosia’ and ‘denial’ interchangeably but differentiate these from ‘loss
of insight’, considering the latter as a distinct and unitary phenomenon. However,
although anosognosia (or denial) is conceived in psychological terms (as a sym-
bolic adaptation to having the disease), albeit in the necessary context of organic
dysfunction, it is not entirely clear on what particular grounds this is differentiated
from loss of insight. A different conceptualisation of ‘anosognosia’ is adopted by
Starkstein et al. (1995a, p. 415) who, following Prigatano and Schacter (1991), define
it as an ‘apparent unawareness, misinterpretation or explicit denial’ thus accepting
a wider and more general notion. Taking yet a different approach, Mangone et al.
(1991) conceive impaired insight following frontal lobe dysfunction as equivalent
to ‘confabulation’. In contrast, they equate impaired insight following right hemi-
sphere dysfunction with ‘anosognosia’. In other words, the concepts in this sense
are defined by putative underlying brain mechanisms. Vasterling et al. (1995), on
the other hand, make a distinction between the concepts of insight and awareness,
defining the former in terms of the global loss of awareness in dementia and the
latter in terms of a domain-specific awareness of deficit. Thus, here the researchers
view insight as the broad concept incorporating the different types of awareness
held in relation to different impairments of dementia.
A much broader and multidimensional conceptualisation of self-awareness or

self-consciousness is offered by Gil et al. (2001). They conceive this as encompass-
ing a wide range of perceptions relating to self-identity and, in empirical terms,
they include awareness of the body, of mental processes (memory, autobiography,
thoughts, etc.) and moral judgements. Likewise, conceiving insight as a broad and
multidimensional structure but approaching this from a ‘person-centred’ perspec-
tive are the views held by Phinney (2002), and Howorth and Saper (2003). In the
former, awareness is seen as inherent to the self and viewed as ‘a way of being in the
world, as an expression of lived experience that may be articulated through narra-
tive’ (Phinney, 2002, p. 331). This takes the concept away from some of the nar-
rower ‘cognitive’ definitions and widens the notion to incorporate more qualitative
aspects relating to the self. Similarly, Howorth and Saper (2003), whilst stressing
the multidimensional aspects of insight as a concept, emphasise the importance of
emotional awareness in its constitution.
The important issue emerging from an examination of the terms and concepts
used in the studies exploring insight in patients with dementia is that studies refer
to a wide range of different concepts of insight. Meanings of insight vary from
simple descriptions of patients not acknowledging problems to more complex
concepts incorporating postulated organic and/or psychological underlying mech-
anisms and range from narrow to wide inclusions (see also below). Some researchers
seem to view lack of insight (or anosognosia) as a ‘symptom’ inherent to dementia
progression (Auchus et al., 1994) and others conceptualise lack of insight more in
terms of disruption of a ‘process’ of self-monitoring (Correa et al., 1996; Kaszniak &
Christenson, 1996). Still others conceive insight in this context as a complex struc-
ture or ‘ability’ constituted by the interplay of a number of cognitive systems such
that dysfunction at different levels or systems can give rise to different forms of
anosognosia (Agnew & Morris, 1998; Duke et al., 2002). In addition, some con-
ceptions focus less on the cognitive aspects of insight but emphasise instead the
importance of including emotional and behavioural aspects to insight and link this
intrinsically to the self (Phinney, 2002; Howorth & Saper, 2003). Moreover, it is
clear that researchers use the terms relating to insight in different ways and that the
distinctions between terms, and the concepts they reflect, vary considerably from
study to study.
5.1.2 Relational aspects of insight

The second issue contributing to the difficulties in determining the meaning of
insight in dementia concerns the focus of insight in empirical studies. Insight is a
relational concept and this carries crucial implications for the meaning of insight
in different situations (Marková & Berrios, 2001). In other words, insight (or aware-
ness) can only be understood or expressed in terms of its relation to something, be
that a pathological state or a non-morbid experience. One cannot have insight

without there being something to have insight about. The term ‘object of insight
assessment’ has been used to refer to the particular mental or physical state (e.g.
mental symptoms, mental illness, neurological abnormality, neuropsychological
deficit, etc.) in relation to which insight is being assessed (Marková & Berrios, 2001).
The importance of this relationship lies in the consequence that follows, namely,
that the ‘object’ itself will determine to a significant extent the phenomenon (i.e.
clinical manifestation) of insight and this theoretical issue is explored in detail in
Chapter 7. For the purposes here, however, it is clear that studies examining insight
in dementia vary also in terms of the ‘object’ chosen for insight assessment. In
other words, empirical studies evaluate insight or awareness in relation to different
aspects of the dementing illness, ranging from considering the illness as a whole
to its individual features and impairments. Many researchers refer to ‘domains’
of awareness in this regard (Kotler-Cope & Camp, 1995; Vasterling et al., 1995;
Neundorfer, 1997) but, for the sake of consistency and for reasons that are discussed
in Chapter 7, the term ‘object’ will be retained here.
Interestingly, compared with studies on insight in mental illness or neurological
states, studies exploring insight in dementia are particularly noticeable by the
number of different ‘objects’ of insight assessment. It is likely that this is a
reflection of the special features of dementia which, as mentioned already, fall into
a number of clinical domains (e.g. neurological impairments, psychological
reactions, functional disabilities and psychiatric problems). Some of the earlier
studies do not directly specify the object of insight and the general implication is
that the insight assessed relates to the disease as a whole (e.g. Schneck et al., 1982;
Danielczyk, 1983). Many studies define memory or cognitive impairment as the
object of insight and do not assess insight into other aspects of the dementia
(Feher et al., 1991; Reed et al., 1993; Lopez et al., 1994; Verhey et al., 1995;
Derouesné et al., 1999; Sevush, 1999). Others concentrate solely on assessing
patients’ insight into their functional abilities (De Bettignies et al., 1990; Mangone
et al., 1991). Still others assess insight in relation to a number of different ‘objects’.
For example, a number of studies examine insight into both cognitive deficits and
functional impairments (Green et al., 1993; Weinstein et al., 1994; Ott et al., 1996a;
Harwood & Sultzer, 2002). Others include further objects of insight evaluation,
such as general health and mood disturbance (Vasterling et al., 1995; 1997), or know-
ledge of progression of dementia (Ott & Fogel, 1992) or behavioural problems/
personality changes (Starkstein et al., 1995a; 1996) or social function (Seltzer
et al., 1997). Anderson and Tranel (1989) specified eight ‘objects’ of insight assess-
ment, namely: reasons for hospitalisation, motor impairments, general thinking
and intellect, orientation, memory, speech and language, visual perception and
abilities on tests, and future activities. And, somewhat different ‘objects’ of insight
assessment were evaluated by Kotler-Cope and Camp (1995), namely, language

disorder, agitation, need for routine, depression, higher cognitive deficits, memory
disorder, dementia, apraxia and disorientation. Interestingly, in addition to assess-
ing insight into cognitive function and activities of daily living (ADL), the study by
Giovannetti et al. (2002) also used naturalistic action errors as their object of insight
assessment. In other words, the researchers here focused on assessing patients’
awareness of any errors they made during normal (specified) every day tasks. Using
their broader conceptualisation of insight or self-consciousness, Gil et al. (2001)
on the other hand explored different objects again, including identity, cognitive
disturbance, affective state, representation of the body, prospective memory,
capacities for introspection and moral judgements.
In addition, even when the object of insight assessment is specified as memory
or cognitive impairment, differences between studies are still present in regards to
the type or aspect of memory impairment that is being evaluated. For example,
some studies focus on insight into a general memory problem (Loebel et al., 1990;
Feher et al., 1991; Verhey et al., 1993; McDaniel et al., 1995), while others assess
insight into specific memory/cognitive deficits or tasks. In relation to the latter,
Green et al. (1993) examine insight into remote memory, recent memory and
attention whilst Michon et al. (1994) assess insight into global memory, recall,
retention, remote memory for personal events, attention and metamemory. Some
researchers, in addition, focus on patients’ awareness of the effects of memory
impairment (Sevush & Leve, 1993) or on the perception of change in memory func-
tioning (McGlynn & Kaszniak, 1991a, b; Vasterling et al., 1995).
5.1.3 Methods of insight assessment in dementia

In order to further clarify the various meanings of insight in relation to dementia,
it is necessary to discuss some of the methods used to assess insight in empirical
studies. Here again, a range of different measures have been developed to assess
insight in patients with dementia. Indeed, the approaches in this clinical area, par-
ticularly as far as systematic measures are concerned, have been more numerous
and more varied in scope than the measures developed to assess insight in general
psychiatry (Chapter 3). Similarly, however, the problem arises as to whether the
different insight measures are eliciting and assessing the same clinical phenom-
enon of insight or whether in fact they elicit different phenomena, with ensuing
consequences for the comparison of study outcomes.
A detailed review of the various measures developed to assess awareness in
dementia has been covered elsewhere (Clare et al., 2005), but it is useful to examine
some of the main differences between insight assessments. The earlier studies tend
not to define their assessment criteria and patients are generally categorised into
those having and those not having insight or awareness into their dementia on the
basis of clinical judgement (Aminoff et al., 1975; Gustafson & Nilsson, 1982; Neary
et al., 1986). More recently, however, attempts have focused on developing system-
atic methods of assessing insight in terms of both categorical and continuous ratings.
Broadly, such insight measures can be divided into: (i) clinician-rated assessments,
(ii) discrepancy measures and (iii) composite assessments which include a number
of different measures.
5.1.3.1 Clinician-rated assessments

Most of the clinician-rated measures consist of structured or semi-structured inter-
views on the basis of which clinicians judge the patient’s insight. This is then rated
either in a dichotomous way with patients deemed as having or not having aware-
ness (Loebel et al., 1990; Lopez et al., 1994; Seltzer et al., 1995b) or on a categorical
basis with generally three or four categories in recognition of ‘partial’ insight or
‘mild’ denial (Sevush & Leve, 1993; Verhey et al., 1993; 1995; Weinstein et al., 1994;
McDaniel et al., 1995). The divisions between categories are determined by criteria
set by the researchers. For example, Sevush and Leve (1993), on the basis of their
interview of patients with Alzheimer’s disease, categorise patients into having
no insight, i.e. no acknowledgement of memory impairment, or partial insight, i.e.
showing some awareness of the presence of memory impairment but not its full
extent, or full insight, i.e. acknowledgment of both the presence and severity of
the memory impairment. On the other hand, McDaniel et al. (1995) using the
Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) structured
interview, have a slightly different emphasis in their categorisation: normal insight –
total insight into the illness and implication, or partial awareness of disease or
implications or unawareness or denial of symptoms of illness. Thus, there are dif-
ferences in terms of detail and specificity of criteria to determine categories between
different studies. Similar categorical divisions have been used to evaluate insight
in patients with Huntington’s disease (Caine et al., 1978) and Parkinson’s disease
(Danielczyk, 1983). However, in addition to the differences between studies in
terms of anchor points for categories, as with any categorical ratings, judgements
will clearly be of a general nature. They cannot therefore address detailed qualita-
tive aspects of insight and will depend very much on the subjectivity of the judger.
Other researchers have developed rating scales so that insight is assessed on a
continuous scale. For example, Ott and Fogel (1992) devised a scale (Insight Rating
Scale) consisting of four areas of questioning relating to four ‘objects’ of insight,
namely, situation, memory impairment, ADL and progression of disease. Each of
these are rated individually from 0 to 2 according to whether clinicians judged the
patient as having good insight (0) up to no insight (2). Thus, a higher score on the
scale indicates a lower degree of insight in the patient. A quite different measure, in
terms of its content, was devised by Gil et al. (2001) whose Self-Consciousness
Questionnaire consists of 14 items relating to their particular ‘objects’ of awareness

assessment (e.g. identity, prospective memory, etc., see above).
Further differences between such clinician assessments are also present in terms
of how the evaluations take place. Thus, some clinician judgements are based on
interviews with patients only (Sevush & Leve, 1993; Weinstein et al., 1994; McDaniel
et al., 1995). Others are carried out in the presence of patient’s relative or carer so
that the judgement takes into account the latter’s views (Loebel et al., 1990; Ott &
Fogel, 1992; Verhey et al., 1993). On the other hand, some researchers have cat-
egorised patients’ insight on the basis of information in case notes only (Reed et al.,
1993; Auchus et al., 1994; Lopez et al., 1994). It seems likely therefore that further
differences in the elicited insight phenomenon will emerge depending on the
source of the information obtained.
5.1.3.2 Discrepancy measures

A great many studies exploring insight in patients with dementia have developed
insight assessments based on discrepancy measures. These measures determine
levels of insight on the basis of discrepancies between the patient’s assessment of
abilities and either: (a) the carer’s (relative’s) assessment of the patient’s abilities
(De Bettignies et al., 1990; Feher et al., 1991; Michon et al., 1994; Starkstein et al.,
1995a,b; Vasterling et al., 1995; Smith C.A. et al., 2000) or (b) ‘objective’ measures of
impairment, such as a battery of neuropsychological tests (Anderson & Tranel,
1989; Dalla Barba et al., 1995; Wagner et al., 1997; Barrett et al., 2005) or (c) a com-
bination of both forms of discrepancy assessments (McGlynn & Kaszniak, 1991a, b;
Green et al., 1993; Correa et al., 1996; Clare et al., 2002; Duke et al., 2002). Such meth-
ods have been important in assessing awareness into neurological states, particu-
larly traumatic head injury (see Chapter 4). Discrepancy measures of insight are
based on the assumption that an ‘accurate’ assessment of an individual’s functioning
can be obtained either directly via another person’s (one who knows the individual
well) observations or indirectly by means of scores on performance in certain tasks.
Such assessments are then compared with the patients’ own assessments of their
functioning and any discrepancy found between patients’ ratings and carers’ ratings
or test scores are attributed to the patient’s lack of awareness or insight into such
functioning. Consequently, the greater the discrepancy that is obtained, the greater
the degree of unawareness or insightlessness shown by the patient. Since the ques-
tionnaires or tests involved are scored (e.g. total score on questionnaire obtained
from patient subtracted from total score obtained by carer, or ratios calculated in
relation to test scores), the discrepancies have ranges of values and hence insight
assessed by such methods is quantified along a continuum of scores.
As far as insight assessments using patient-carer discrepancy are concerned, the
main differences between questionnaires used in the various studies relate to different
‘objects’ of insight and/or to different types of judgements contained in the con-

tents. The issue around different ‘objects’ of insight has already been mentioned
and relates to the questionnaires addressing different aspects of dementia in rela-
tion to which insight is assessed. Thus, some questionnaires focus on ADL, and
patients and carers are required to rate patients’ abilities in those particular areas
(e.g. De Bettignies et al., 1990; Mangone et al., 1991). Other questionnaires focus
on memory and/or other cognitive problems (e.g. Feher et al., 1991; Michon et al.,
1994; Seltzer et al., 1995b). Still others use questionnaires addressing both these areas
(e.g. Seltzer et al., 1997) and additional ones, such as mood changes, behavioural
problems and others (e.g. Kotler-Cope & Camp, 1995; Starkstein et al., 1995a;
Vasterling et al., 1995; Deckel & Morrison, 1996; Smith C.A. et al., 2000; Snow et al.,
2004). In addition to these differences in ‘object’ of insight there are, however, also
differences in the types of judgements that patients and carers are being asked to
make. For example, some questionnaires focusing on evaluations of memory ask
patients (with parallel questions for the carers) to rate the degree of severity of
problems they perceive as having with their memory (Green et al., 1993; Duke et al.,
2002). Other questionnaires, also focusing on memory evaluations, ask patients to
rate their memory as compared with some years previously (McGlynn & Kaszniak,
1991a, b; Michon et al., 1994) or even as compared with others of a similar age
(Deckel & Morrison, 1996). On the other hand, some questionnaires ask patients
to rate the frequency with which they make mistakes in various memory-related tasks
(Migliorelli et al., 1995; Starkstein et al., 1996; Seltzer et al., 1995b; Derouesné et al.,
1999). Some studies include various mixtures of such types of judgements (e.g.
Feher et al., 1991; Clare et al., 2002). In other words, as with similar discrepancy
measures used in, for example, head injury, the various measures demand different
types of judgements from patients (and carers). This is important to highlight, not
just because the overt content of such questionnaires may be different, but also
because such specific judgements themselves may well be contributing to the elic-
itation of different phenomena of insight. Being asked to evaluate the severity of
current problems with memory may involve quite different sorts of judgements
from those made when comparing memory with that of other individuals or with
memory from some years previously. Thus, whilst the various questionnaires elicit
some aspects of insight, it is questionable whether in fact the same or similar
aspects of insight are assessed in studies using different questionnaires even if all
are purporting to measure insight into memory problems (Hermann, 1982).
Apart from such differences between individual questionnaires, questionnaire
discrepancy measures raise a number of other important issues concerning their
validity as measures of patients’ insight. There is firstly the question concerning the
extent to which a ‘carer/relative’ can be expected to provide an accurate evaluation
of a patient’s functioning in different areas. For various reasons, carers may both
overestimate or underestimate levels of impairments in patients. For example,

De Bettignies et al. (1990) examining discrepancies between patients and carers in
evaluation of patients’ independent living skills found that whilst patients’ insight
was not correlated with age, mental status, education or level of depression, it was
significantly related to the degree of caregiver concern or burden. In other words,
the higher the degree of burden perceived by the carer, the higher the discrepancy
(i.e. lower patient insight) between patient and carer assessments. The authors sug-
gested that the high discrepancy in this situation was not only due to the patients’
overestimation of living skills but that carers with greater perceived burden were
underestimating the capacity of patients. Other factors might also play a part in
carers’ underestimating patients’ functioning including carers’ mental states, phys-
ical health, relationship with patient, etc. Similarly, carers might equally overestimate
patients’ function in different areas again because such judgements will depend to
some extent on individual factors relating to the carer, e.g. mental state of carer,
extent of denial, motivation to keep patient ‘well’ (e.g. because of driving), level of
knowledge concerning the patient, etc.
In general, studies exploring the ‘accuracy’ of carers’ evaluations of patients in
different areas have found reasonably good correlations between carers’ assessments
and other measures of patients’ functioning. For example, in memory assessments,
in contrast to patients’ own evaluations, carers’ evaluations of patients’ memory
difficulties have correlated significantly with neuropsychological tests of memory
function in patients (McGlone et al., 1990; Grut et al., 1993; Koss et al., 1993; Jorm
et al., 1994; McLoughlin et al., 1996). Interestingly, the study by Jorm et al. (1994)
also found that carers’ ratings of patients’ cognitive state were influenced by depres-
sion and anxiety experienced by carers. The type of carer involved (in terms of rela-
tionship of carer to patient or degree of contact with patient) has sometimes been
found to relate to the ‘accuracy’ of carer evaluation. For example, McLoughlin et al.
(1996) found that spouses’ evaluation of patients’ memory correlated more
strongly with neuropsychology tests than first degree relatives’ evaluations and that
second degree relatives’ evaluations of patients’ memory function had no signifi-
cant correlation with memory tests.
Similarly, in assessments of daily living activities, carers’/relatives’ evaluations of
patient function have been more strongly correlated with ‘objective’ tests of ADL
than patients’ evaluations (Kuriansky et al., 1976). Interestingly, examining differ-
ences in the assessments of ADL of elderly physically ill patients, Rubenstein et al.
(1984) found that, using structured scales, patients evaluated themselves as func-
tioning significantly better compared with the evaluations by their relatives whilst
nursing staff ’s evaluations fell intermediate between those of patients and carers.
In other words, it is clear that individual factors are important in determining such
assessments. The researchers highlighted the issue, inherent in any questionnaire
discrepancy methods, that it may not be possible to distinguish between overesti-

mations made by subjects and underestimations made by others.
In the case of evaluating depressive symptoms, the questionnaire discrepancy
methods are beset by additional problems because of the problems involved in oth-
ers judging the ‘subjective experiences’ of individuals. Studies have shown discrep-
ancies between the evaluations made by patients, relatives and clinicians, with
patients generally underreporting depressive symptomatology compared with car-
ers or clinicians (Mackenzie et al., 1989; Teri & Wagner, 1991; Logsdon & Teri, 1995;
Snow et al., 2005). However, Burke et al. (1998) showed that carers/relatives rated
not only patients with Alzheimer’s disease as more depressed, compared with
patients’ evaluations, but they also rated patients without cognitive impairment as
more depressed. The authors suggested that the discrepancy reflected exaggeration
of problems on the relatives’ part and that this in turn might relate to their perceived
burden of care. In other words, the study emphasised the importance of individual
factors, both patient and carer related, that might contribute to discrepancies and
the difficulty in distinguishing between such factors to determine to what extent a
discrepancy measure can evaluate a subject’s awareness or insight of problems.
Secondly, apart from the question of carer ‘accuracy’ in assessing patients’ func-
tion, other issues concerning questionnaire discrepancy methods need to be con-
sidered. Sevush (1999) raised the problem (applied to both questionnaire and
performance discrepancy measures) that carer assessments (and test performance)
will inherently incorporate assessments of dementia severity itself. Thus, studies
using discrepancy measures of assessing patients’ insight to examine the relationship
between patients’ insight and severity of dementia may show inflated correlations
because the ‘severity of dementia’ variable will be both a dependent and independent
variable in the correlations obtained. Another problem concerning questionnaire
discrepancy methods relates to the way the scores are calculated. These tend to be
composite scores based on the totals derived from patients and carers. However, indi-
vidual items on the measures could be discrepant in different ways and these could
be lost when total scores are used. In addition, some discrepancy measures use cut-
off points to determine patients with and without insight (Migliorelli et al., 1995;
Starkstein et al., 1995a; 1997b, etc.) and thus again information might be lost as only
patients at either extremes are included in the analysis (Lamar et al., 2002).
Discrepancy methods using performances on ‘objective’ psychometric tests,
rather than carers’ assessment, as the gold standard against which patients’ insight
is derived, are complicated by other issues. Such neuropsychological tests are rela-
tively detailed and specific, and have little in common with memory/cognitive
problems that come up in daily life. Yet, patients’ awareness of memory or cogni-
tive problems is determined by the discrepancy in their scores on such tests and
their subjective assessment on a global rating of how severe they believe their memory
problem to be (e.g. Anderson & Tranel, 1989; McGlynn & Kaszniak, 1991a, b). As
others point out (Hermann, 1982; Sunderland et al., 1983; Larrabee et al., 1991;
Trosset & Kaszniak, 1996), the poor correspondence between what the tests are
assessing and what the patients are being asked to assess makes it difficult to attri-
bute the size of discrepancies solely to patients’ impaired awareness of cognitive
problems. Some researchers have attempted to reduce this particular problem by
devising measures that are more practically relevant to the individual (e.g. Clare
et al., 2002) and by the use of prediction and/or postdiction discrepancy methods.
In the former, specific neuropsychological tests (e.g. recall of word lists) are first
explained to the patients and then they are asked to predict how they would perform
on such tests. The discrepancies between patient predictions and actual perform-
ance are taken as a measure of patient awareness (e.g. McGlynn & Kaszniak, 1991a, b;
Green et al., 1993). In the latter, again, the tests are first explained to the patients,
but in this case the patients are asked to rate how well they have performed only
after completing the tests. The discrepancies between patient performance and their
postperformance assessments are taken as reflecting their insight into their cogni-
tive problems (Correa et al., 1996).
Within the metamemory framework, focusing on self-monitoring (rather than
awareness or insight), some studies have assessed patients’ predictions on recall
tests following practice (Moulin et al., 2000). Others have differentiated between
assessments based on patients’ predictions of recalling and those based on patients’
predictions of recognising (feeling-of-knowing) words from lists (Souchay et al.,
2002). However, the crucial point is that irrespective of the specific design of such
discrepancy methods, the phenomenon of awareness or insight elicited by the dif-
ferent methods (test performance, prediction, postdiction) will vary accordingly.
Thus, depending on the test’s demands (both in content and design), it will incorp-
orate different types of judgements into the discrepancy measure. Consequently,
the different assessments will elicit different aspects of insight. Trosset and Kaszniak
(1996) argue that discrepancy measures, based on psychometric tests, reflect not
only patients’ awareness of cognitive problems but also their judgements concern-
ing the difficulties of such unfamiliar tests. They suggest that one way to distin-
guish between these types of judgements is to consider also patients’ assessments
of their relatives’ performances on the tests as well as the relatives’ assessments of
themselves and the patients on the same tests. However, clearly all sorts of add-
itional judgements would then complicate the ensuing assessment and it might be
difficult to tease out individual aspects. Nevertheless, some studies have devised
insight measures that have included a combination of patients’ and carers’ predic-
tions (McGlynn & Kaszniak, 1991a, b), and postdictions of own and the others’
functioning as well as predictions and postdictions of the performance of an unfamil-
iar person (videotaped interview) on memory tests (Duke et al., 2002).
5.1.3.3 Composite measures

In recognition of the likely different aspects of insight elicited by the various
approaches, some researchers have employed combinations of both clinician-rated
assessments and discrepancy measures in an attempt to provide a more global and
comprehensive picture of insight (Correa et al., 1996; Ott et al., 1996a; Derouesné
et al., 1999; Howorth & Saper, 2003). Similarly, acknowledging the assumptions
involved when using carers’ information as the gold standard against which patients’
responses on questionnaires are assessed, Snow et al. (2004) devised a more com-
posite instrument to assess deficits in awareness about dementia. This includes not
only discrepancies between patients and carers but also discrepancies between
patients and clinicians. Thus, they developed three parallel forms of their Dementia
Deficits Scale to be independently completed by patients, carers and clinicians.
They emphasised the need to consider the biases of the different proxies involved,
and argued that the different perspectives thus collected added unique informa-
tion to the capture of patients’ self-awareness as a whole.
In addition, some studies have also included novel ways of assessing insight. For
example, Giovannetti et al. (2002), apart from using discrepancy methods also
included a clinician-rated evaluation of patients’ insight that was based on directly
observed behaviours (videotaped). Insight in the latter situation was inferred on
the basis of patients’ reactions to and attempts at self-corrections of mistakes occur-
ring during the course of three set everyday tasks. Similarly, Bologna and Camp
(1997) in a small study inferred the presence of insight in patients on the basis of
self-recognition in a mirror reflection. Clare (2003), on the other hand, attempted a
more in-depth assessment of insight by exploring patients’ awareness in detailed
interviews focusing on patients’ understanding in the context of their individual
and social backgrounds. The interviews were taped and interpretative phenom-
enological analysis was used to construct a model of awareness within a psycho-
social context.
5.2 Relationship between insight, clinical and socio-demographic variables
Interest in the empirical exploration of insight in dementia particularly over the

last 15 years seems to have arisen from various perspectives. As in relation to the
research on insight in ‘functional’ psychiatric disorders, questions appear to converge
predominantly on the nature of insight as a phenomenon. In contrast to the ideas
on insight in psychoses, the debate on the nature of insight (or rather insightlessness)
in dementia is, with a few exceptions (Clare, 2003), much more clearly polarised. In
this sense, it is generally viewed either as a symptom inherent to the dementia process
itself or as a psychological reaction inherent to the individual. Whilst these aspects
of insight are likewise raised in general psychiatry (see Chapter 3), there is a less
explicit division there. Furthermore, there is in addition a third position held in gen-
eral psychiatry, namely that of insight conceived as an independent phenomenon
or process, in the sense of being independent of both the disorder itself and of the
psychology or reactivity of the individual. In dementia studies, the polarity between
unawareness as intrinsic to the disease process and unawareness as a psychological
denial seems to have been driven to a considerable extent by the work on anosog-
nosia in non-progressive organic brain disorders (see previous chapter). Focus on
insight in empirical studies has thus been aimed predominantly at two issues.
Firstly, researchers have focused on developing understanding of the dementia
process itself. In other words, studies attempt to relate insight with disease severity
and to explore changes in insight in relation to different dementias or brain/neuro-
psychological dysfunction. Secondly, researchers have sought to examine the
changes and reactions of the person with dementia. In other words, studies explore
the relationship between insight and various moods and behavioural changes, such as
depression/anxiety, etc. From a slightly different perspective, interest in the explo-
ration of insight in dementia has also been generated from a wider consideration of
the patient and family affected by the disease and its consequences. Hence, studies
have attempted to consider the rehabilitation potential of insight (mirroring work
on insight in relation to traumatic brain injury), its prognostic value and the
effects of impaired insight on the family/carers looking after the patient.
It is perhaps not surprising that, in general, results of empirical studies explor-
ing the relationship between insight, clinical and socio-demographic variables are
as inconclusive in relation to dementias as they are in relation to functional psy-
chiatric syndromes. Once again it is likely that the differences identified in the way
insight is defined and conceptualised, the variable ways in which it is assessed, the
range of ‘objects’ of insight involved as well as the fact that different outcome meas-
ures are used will all contribute to the mixed and inconsistent results. This makes
it difficult to answer in a definite way some of the questions posed concerning the
nature of insight as a clinical phenomenon and its relationship to both the indi-
vidual and to the disease process.
5.2.1 Insight and socio-demographic variables

Searching for associations between insight and socio-demographic variables is a
means of exploring only fairly general characteristics of insight that could be related
to the individual and/or the disease. Overall there is more consistency between the
studies reporting on such correlations than in other areas. Most studies report no
significant correlations between the degree of patients’ insight and variables, such
as age (or age of disease onset) of the patient, education level or duration of illness
(De Bettignies et al., 1990; Feher et al., 1991; Reed et al., 1993; Auchus et al., 1994;
Starkstein et al., 1995a; Vasterling et al., 1995; 1997; Sevush, 1999; Gil et al., 2001;
Giovannetti et al., 2002). There are a few exceptions. For example, Sevush and Leve
(1993), whilst finding no association between denial and age of onset of Alzheimer’s
disease, years of education or duration of illness, found, nevertheless, a significant
correlation with gender, females showing more denial (less insight) than males. On
the other hand, Migliorelli et al. (1995) reported in their study that males showed
significantly more anosognosia (less insight) than females. Similarly, whilst most
studies find no association between insight and the age of the patient, a few stud-
ies report a negative correlation between insight and age, i.e. the greater the age, the
lower the patient’s awareness (Verhey et al., 1993; Weinstein et al., 1994; Derouesné
et al., 1999). And, likewise, duration of illness has not been found to correlate with
insight in most studies but a few have reported a negative correlation, i.e. less
insight associated with longer duration of illness (Migliorelli et al., 1995; Starkstein
et al., 1996; 1997a).
Given the few significant correlations between insight and socio-demographic
variables, in the face of mostly non-significant findings, it is difficult to interpret
very much. As is seen from Table 5.1, the studies vary in their methodologies, par-
ticularly, in their measures of insight and it is likely that different aspects of insight
are elicited which, in turn, is likely to affect the correlation sought. Moreover, vari-
ables such as duration of dementia can be very difficult to ascertain given the lack
of detailed understanding around the disease process.
5.2.2 Insight in different types of dementia

Exploring the relationship between impairment of insight and different types of
dementia means, essentially, addressing the question of whether impaired insight
is a symptom or process that is specific to the disease itself rather than to the indi-
vidual. In other words, if patients were to show more impaired insight according to
the type of dementia affecting them, then perhaps insight could be conceived as
intrinsic to the particular pathological process associated with that dementia. Most
work on insight has, in fact, been carried out in Alzheimer’s disease (Table 5.1, most
studies use the NINCDS-ADRDA (McKhann et al., 1984) criteria for probable
Alzheimer’s disease) and there has been little systematic work undertaken in other
types of dementia. In general, it is claimed that patients with cortical dementias
(e.g. Alzheimer’s disease, Pick’s disease/frontal lobe dementia) show greater loss
of insight than patients with subcortical dementias, e.g. Huntington’s disease,
Parkinson’s disease, etc. (Kaszniak & Christenson, 1996; Lishman, 1998). Pick’s dis-
ease and/or frontal lobe dementia have been noted particularly for a marked and
early loss of insight (Gustafson & Nilsson, 1982; Neary et al., 1986; Orrell & Sahakian,
1991). On the other hand, studies exploring insight in subcortical dementias such
as Huntington’s disease or Parkinson’s disease have remarked on the relative
preservation of insight in these patients (Aminoff et al., 1975; Caine et al., 1978;
Caine & Shoulson, 1983; Danielczyk, 1983). Caine et al. (1978) commented on
patients with Huntington’s disease showing not only insight into their cognitive
problems but also into changes of temperament or disposition, and into difficul-
ties in controlling their affect. However, most of these studies have not used any
structured assessments of insight nor provided defined criteria for establishing the
presence or absence or partial presence of insight.
Some studies using structured insight assessments (albeit of different kinds)
have explored differences in insight between patients with Alzheimer’s disease and
vascular dementias. One of the issues to consider here is the validity of using the
Hachinski criteria (Hachinski et al., 1975) to distinguish between Alzheimer’s dis-
ease and vascular or multi-infarct dementia which has been subject to some criti-
cism (e.g. Dening & Berrios, 1992). Interestingly, studies have shown opposing
results. Thus, some researchers have found no difference in the insight shown
between patients with Alzheimer’s disease and those with vascular dementias
(Verhey et al., 1993; 1995; Zanetti et al., 1999; Giovannetti et al., 2002). However,
other studies report a significant difference in insight between the groups, with
Alzheimer’s disease patients showing greater impairment of insight than patients
with vascular disease (De Bettignies et al., 1990; Wagner et al., 1997). Again, little
can be concluded at this stage and the differences in methodologies of the studies
are described in Table 5.1. More systematic work is needed to be able to address the
question of differences in patients’ insight in different dementias and such work
continues to be additionally problematic in the face of practical difficulties around
determining onset/stage of disease and its severity.
5.2.3 Insight in relation to severity, stage and progression of dementia

Questions concerning the relationship between patients’ insight and the severity,
stage and/or progression of their disease are, once again, aimed at determining to
what extent impairment of insight is intrinsic to the disease process (and progres-
sion) and, hence, part of its ‘pathology’ as opposed to representing a psychological
reaction to knowledge of the consequences of having dementia.
As can be seen from Table 5.1, studies exploring the relationship between
patients’ insight and the severity of their dementia also yield variable results. Many
studies report a strong positive correlation between poor insight and more severe
dementia (e.g. Mangone et al., 1991; Verhey et al., 1993; Lopez et al., 1994; Seltzer
et al., 1995a, b; Vasterling et al., 1995; Correa et al., 1996; Harwood et al., 2000;
Duke et al., 2002; Vogel et al., 2005). Others report only a weak association between
severity of dementia and poor insight (e.g. Feher et al., 1991; Michon et al., 1992;
Ott et al., 1996b; Sevush, 1999). Yet, others find no relationship between insight
and severity of dementia (e.g. Loebel et al., 1990; Green et al., 1993; Reed et al.,
1993; Weinstein et al., 1994; Dalla Barba et al., 1995; Giovannetti et al., 2002;
Table 5.1 Studies of insight in dementia: relationship with clinical/socio-demographic variables
168
Main results
‘Object’ of Insight
Study Patients insight assessment Outcome variables Dementia /behavioural Other
Anderson and CVA: 32 Cognitive Discrepancy Neuropsychology Poor insight – No difference

Tranel (1989) AD: 29 and motor between patient tests: 1–8 associated with in insight across
MID: 5 deficits assessment and Computerised right hemisphere diagnostic groups
MD: 15 performance on tomography (CT) damage and
HT: 19 neuropsychology and/or magnetic lower intelligence
tests resonance image quotient
(MRI)
De Bettignies AD: 12 Independent Discrepancy PSMS AD patients had No association Poor insight
et al. (1990) MID: 12 living skills between patient IADL lower insight between insight associated with
Elderly and carer on HDRS than VD and and depression greater carer’s
control: 12 questionnaire controls burden
Loebel et al. AD: 32 Memory Clinician-rated MMSE No difference in – Poor insight
(1990) problems structured Fluency Rating severity of associated with
interview of Scale dementia between better speech
patient and carer patients with and fluency
without insight
Feher et al. AD: 38 Memory Discrepancy MMSE Weak correlation Weak correlation –
(1991) problems between patient GDS between poor between poor
and carer on HDRS insight and more insight and less
questionnaire Neuropsychology severe dementia depression
tests: 4, 9,10
McGlynn and AD: 8 Memory 1. Discrepancy MMSE Poor insight – Patients over-
Kaszniak (1991a) problems between patient Neuropsychology associated with estimated own
and carer on tests: 11–22 more severe function but
questionnaire dementia accurate in
2. Discrepancy estimating carers’
169
between patient abilities
prediction and
performance on
cognitive tests
McGlynn and HD: 8 Memory As above and MMSE Poor insight – Poor insight with
Kaszniak (1991b) problems discrepancy Neuropsychology associated with questionnaire
Motor between patient tests: 10, 19, 22 more severe discrepancy
problems prediction and Motor tasks: a–e dementia Better insight on
performance on prediction tests
motor tests
Mangone et al. AD: 41 Physical self- Discrepancy MMSE, GDS, Poor insight Poor insight –
(1991) maintaining between patient BDRS, BPRS associated with more frequent
activities and carer on Neuropsychology more severe in patients
Activities of questionnaire tests: 9, 23–30 dementia with paranoid
Daily Living Best predictors delusions
(ADL) of poor insight:
GDS, BPRS,
tests: 23, 27
Michon et al. AD: 15 Memory Discrepancy MMSE Minimal – –

(1992) problems between patient Neuropsychology correlation
and carer on tests: 22, 31–34 between poor
questionnaire insight and
severity.
Significant
correlation
between poor
insight and
‘frontal’ tests
170
Table 5.1 (cont.)
Main results
Ott and Fogel AD: 37 1. Reason for Clinician rating MMSE, CDRS Poor insight Mixed association –
(1992) VD and clinic visit on scale in the HDRS, COR, associated with between insight
others: 13 2. Memory four areas based GerDS more severe and depression,
problems on information dementia depending on
3. ADL from patient depression scale
4. Progress and carer (see text)
of deficits
Green et al. (1993) AD: 20 1. Remote 1. Discrepancy Neuropsychology No association – Least insight into
memory between patient tests: 2, 35 between insight recent memory
2. Recent and carer on DRS and severity and ADL.
memory questionnaire of dementia No correlation
3. Attention 2. Discrepancy between the two
4. Daily between patient insight measures
activities prediction and
performance on
cognitive test
Reed et al. (1993) AD: 57 Memory Clinician rated MMSE, DSM-III No association No association Poor insight
problems from case notes. (for depression) between insight between insight associated with
Scale identified Neuropsychology and severity and depression reduced perfusion
four categories tests: 35–38 of dementia. in right
SPECT (n 20) Poor insight dorsolateral
associated with frontal areas
poor recognition
memory
Sevush and Leve AD: 128 Memory Clinician-rated ACAD Poor insight Poor insight –
171
(1993) problems structured Three-item scale associated with associated with
interview: three for depression more severe less depression
categories cognitive deficits
Verhey et al. AD: 103 Cognitive Clinician- GDS Poor insight No correlation –
(1993) VD: 43 deficits rated structured DSM-III-R associated with between insight
Others: 24 interview of (for depression), more severe and depression.
patient and carer HDRS dementia Correlation
between poor
insight and less
psychic anxiety
(HDRS)
Auchus et al. AD: 28 Cognitive Clinician rating DRS No association – –
(1994) deficits from case notes Neuropsychology between insight
tests: 2, 9, 27, and severity of
36–39 dementia.
Correlation
between poor
insight and poor
visuo-constructive
skills (38, 39)
Feher et al. (1994) AD: 83 Memory Self-report HDRS Poor insight Poor insight
AAMI: 200 problems of memory Neuropsychology associated with associated with
Conrols: 64 problems on tests: 4, 9, 10 more severe less depression
questionnaire dementia
Kiyak et al. (1994) AD: 40 1. Functional Discrepancy DRS Insight worse – Longitudinal
Control: 53 health between patient over time, in asso- study: partial
Follow-up 2. General and carer on ciation with decline preservation of
study health questionnaire of cognition insight over time
Table 5.1 (cont.)
172
Main results
Lopez et al. (1994) AD: 181 Cognitive Clinician rating Structured Poor insight No difference –
deficits from case notes interview; associated with in depression,
DSM-III-R. more severe delusions or
Neuropsychology dementia. hallucinations
tests: 3, 5, 25, Poor insight between patients
31, 36, 40–45 associated with with and
poor frontal tests without insight
Michon et al. AD: 24 Memory Discrepancy MMSE, MADRS No correlation No correlation –
(1994) problems between patient Neuropsychology between insight between insight
and carer on tests: 22, 31, 32, and severity and and depression
questionnaire 36, 38 most of tests.
Behavioural Significant
observations correlation
(Luria) between poor
insight and poor
‘frontal’ tests
Weinstein et al. AD: 41 1. Memory Clinician-rated MMSE No correlation Poor insight Poor insight more
(1994) Followed up problems structured Neuropsychology between insight associated with often when AD
also after 2. ADL interview: three tests: 39, 46, 47 and severity or confabulation, presented initially
2–3 years categories history. with any of tests delusions, with memory
Premorbid misidentification, or behavioural
personality rating symbolic changes
disorientation
Dalla Barba et al. AD: 12 Memory Discrepancy MMSE, BDRS, No correlation Depressed –
(1995) DD: 12 problems between patient MADRS between insight patients had less
Controls: 24 rating of memory Neuropsychology and ‘frontal’ tests insight into
and performance tests: 22, 48–50 Poor insight memory, and
173
on memory tasks Occurrence of correlated with overestimated
‘intrusions’ more intrusions memory more
than AD, but
not statistically
significant
Kotler-Cope and AD: 13 nine objects – Discrepancy RBMT No correlation – Better insight for
Camp (1995) including between patient between insight and behavioural
cognitive, mood and carer on and severity problems than
and behaviour questionnaire of dementia for cognitive.
McDaniel et al. AD: 670 Cognitive Clinician-rated MMSE, CDRS Poor insight – Reduction of
(1995) After deficits direct question- BDRS correlated with insight over time
follow-up: ing: three BDRS-short more severe correlated with
1 year: 406 categories dementia greater severity
2 years: 148
Migliorelli et al. AD: 73 1. Cognitive Discrepancy MMSE, CDRS Poor insight Poor insight –
(1995) deficits between patient HDRS, HAS correlated with associated with
2. Personality and carer on FIM, STC, more severe more mania,
and interests questionnaire BMS, PLACS cognitive and pathological
(AQ-D): cut-off Neuropsychology ADL deficits laughing and
point for those tests: 4, 19, 32, No correlation less dysthymia
with and without 36–38, 43, 51–54 with specific tests and anxiety.
insight No correlation
with major
depression
Seltzer et al. AD: 226 Memory Clinician-rated MMSE, CDRS Poor insight Patients with –
(1995a) problems set questions: BDRS: BMIC associated with insight had
two categories and BPEA later stage and significantly more
(with and without interview more severe depressed mood
insight) dementia (not disorder)
174
Table 5.1 (cont.)
Main results
Seltzer et al. AD: 36 Memory Discrepancy MMSE Poor insight Poor insight –
(1995b) problems between patient COR correlated with associated with
and carer on Three 5-point more severe less depression
questionnaire Likert scales to dementia and more carer-
(EMQ) assess mood rated irritability
Starkstein et al. AD: 24 1. Cognitive Discrepancy MMSE, HDRS, No difference No difference Patients with no
(1995a) deficits between patient FIM, STC in severity or in depression, insight had
2. Personality and carer on Neuropsychology test scores ADL and social reduced cerebral
and interests questionnaire tests: 4, 19, 32, between patients ties between blood flow in
(AQ-D) 36–38, 51–54 with and without patients with and right hemisphere
SPECT insight without insight
Vasterling et al. AD: 43 Memory, Discrepancy MMSE, CDRS Poor insight – Least insight in
(1995) general between patient associated with self-care and
health, self- and carer on later stage and memory.
care, mood questionnaire more severe Best insight in
(EMQ, GQ) dementia depression and
general health
Verhey et al. AD: 48 Cognitive Clinician-rated GDS, BDRS Poor insight – No difference
(1995) VD: 48 deficits structured DSM-III-R associated with in insight or
interview of (for depression) more severe depression
patient and carer HDRS dementia between AD
and VD
175
Correa et al. AD: 20 Memory 1. Discrepancy MMSE Poor insight – AD showed poorer
(1996) MII: 18 problems between patient Neuropsychology associated with insight into
Controls: 18 and carer on tests: 3, 4, 22, 55 more severe memory problems
questionnaire dementia compared with
2. Discrepancy memory impaired
between post- older adults
diction and
performance on
cognitive tests
3. Number of
intrusions and
self-corrections
Deckel and HD: 19 Cognitive Discrepancy Neuropsychology Poor insight – HD had less
Morrison (1996) Controls: 14 and motor between patient tests: 2, 5, 31, 32, associated with insight than
(Neuro- problems and and staff ratings 37, 43, 56 more impairments neurological
impaired) emotions on questionnaire on tests controls
Ott et al. (1996a) AD: 26 1. Reason for 1. Clinician rated MMSE Poor insight No association AD had less
Controls: 16 clinic visit (Ott & Fogel, COR associated with between insight insight into
2. Memory 1982, above) Neuropsychology poor performance and depression memory and
problems 2. Discrepancy tests: 19, 36, 37, on executive and ADL than
3. ADL between patient 39, 43, 57–59 visuo-spatial tests elderly controls
4. Progress and carer on
of deficits questionnaire
for memory
and ADL
Ott et al. (1996b) AD: 40 1. Reason for Clinician rated MMSE Poor insight Poor insight Patients with
clinic visit as above (Ott & IADL, PSMS, correlated with correlated with poor insight had
Table 5.1 (cont.)
176
Main results
2. Memory Fogel, 1982) DBDS worse ADL more apathy lower perfusion
problems SPECT Small correlation in right temporo-
3. ADL between poor occipital cortex
4. Progress insight and
of deficits severity
Starkstein et al. AD: 170 1. Cognitive Discrepancy MMSE, HDRS, Poor cognitive Poor insight (cog) Factor analysis
(1996) deficits between patient HAS, AS, IS, (but not correlated with yielded two
2. Personality and carer on BMS, PLACS, behavioural) more delusions, factors: cognitive
and interests questionnaire DPS, FIM insight correlated apathy and less insight and
(AQ-D) interview with more severe depression. behavioural
Neuropsychology deficit on NP tests Poor insight insight
tests: 19, 32, 37, (beh) correlated
38, 51, 53, 54, 60 with mania and
pathological
laughing
Seltzer et al. AD: 40 Memory, Discrepancy MMSE, CDRS Poor insight in – Greater carer
(1997) self-care and between patient BIZ social and self- burden associated
social function and carer on care (not memory) with poorer
questionnaire function associated insight (into
(EMQ, PCRS) with more severe memory – not
dementia into self-care)
Starkstein et al. AD: 62 1. cognitive Discrepancy MMSE, HDRS, Insight gets worse Insight associated –
(1997a) Follow-up deficits between patient interview with progression with dysthymia
study 2. personality and carer on DSM-III-R of dementia but not with
and interests questionnaire (SCID), HAS major depression
(AQ-D) FIM, DPS, (poor insight with
BMS, OAS less depression)
177
Starkstein et al. AD: 55 1. Cognitive Discrepancy MMSE Poor insight asso- – –
(1997b) deficits between patient interview ciated only with
2. Personality and carer on Neuropsychology poor set shifting
and interests questionnaire tests: 4, 19, 36–38, and procedural
(AQ-D) 43, 52–55, 61 learning
Vasterling et al. AD: 28 Memory, Discrepancy MMSE Insight decrease – Insight falls in
(1997) Follow-up general between patient not correlate relation to all
study health, self- and carer on with progress of ‘objects’ over
care, mood questionnaire dementia time, no difference
(EMQ, GQ) in size
Wagner et al. AD: 73 Cognitive Discrepancy MMSE AD had poorer – –

(1997) VD: 23 deficits between patient insight than VD
Elderly rating of function and others
controls: 17 and performance independent of
Elderly on cognitive tests severity
controls: 19
Cotrell and AD: 35 1. Remote Discrepancy MMSE, CDRS Poor insight – Only poor insight
Wild (1999) memory between patient ADL, IADL correlated with into attention
2. Recent and carer on 15-item more severe predicted patients
memory questionnaire questionnaire (MMSE) who no longer
3. Attention (Green et al., on driving dementia drove
4. Daily 1993, above)
activities
Derouesné et al. AD: 88 After Cognitive 1. Discrepancy MMSE, ADL Poor insight Poor insight Poor insight
(1999) follow-up deficits between patient ZD, ZA, PBQ correlated with correlated correlated with
of 21 and carer on Neuropsychology worse MMSE at mainly with lower perfusion
months: 52 questionnaire tests: 22, 31, 54, first visit but more apathy in frontal
Table 5.1 (cont.)
178
Main results
2. Clinician rated 60, 66 not at follow-up. and with less cerebral regions
3. Carers’ ratings Frontal behaviours Correlation with anxiety.
SPECT ADL at both visits. No correlation
No correlation with depression.
with tests
Sevush (1999) AD: 203 Memory Patient-rated MMSE A small correlation – Greater correlation
Controls: 40 problems questionnaire ACAD between between poor
After (AMIS) poor insight insight and
follow-up of Also ratings by and severity at severity when
15 months: clinician and first visit but using clinician
AD: 106 discrepancy no correlation or discrepancy
measures used with progress measures
to compare of disease
Zanetti et al. AD: 37 Memory 1. Clinician-rated MMSE, CDRS, Poor insight No correlation No difference in
(1999) VD: 32 problems and interview (Verhey ADL, IADL correlated with between insight insight between
objects from et al.,1993, above) GerDS, NPI more severe and depression AD and VD
Ott and Fogel 2. Clinician-rated Neuropsychology dementia and
(1982, above) questions (Ott & tests (n 36): 5, 9, cognitive
Fogel, 1982, above) 19, 22, 32, 36, 54, 67 impairment but
complex (see text)
Harwood et al. AD: 91 Cognitive and Clinician rated: MMSE, NRS Poor insight Poor insight –
(2000) functional Item 12 BDRS-short associated with associated with
deficits (inaccurate more severe less depression but
insight item) dementia more agitation
from NRS No correlation
with psychosis
Smith C.A. et al. AD: 23 Cognitive, Discrepancy MMSE, GerDS No correlation Poor insight After controlling
179
(2000) Controls: 30 motor and between patient Neuropsychology between insight associated with for depression,
affective and carer on tests: 8,19, 37, 38, and severity, less depression poor insight
problems questionnaire 43, 57, 68, 69 except after correlated with
controlling for severity and with
depression poor frontal tests
(see text) performance
Gil et al. (2001) AD: 45 Identity, Clinician-rated MMSE Poor insight – Different ‘objects’
cognition, questionnaire Neuropsychology correlated with of insight affected
affect, body, answered by tests: 70 more severe to different extents
prospective patients (SCQ) dementia Body and identity
memory, No correlation least affected
introspection, with frontal tests
moral
judgements
Koltai et al. (2001) D: 22 Cognitive Clinician rated: MMSE, GerDS, Patients with – Relatives perceived
Randomised deficits two categories GerDS-rel., EMQ, insight made greater gains with
controlled (with and EMQ-rel. greater gains in MCP independent
trial with without insight) Neuropsychology memory with of insight
Memory and tests: 36, 57, 58 MCP than
Coping those without
Programme
(MCP)
Duke et al. (2002) AD: 24 Cognitive Discrepancy MMSE, DRS Poor insight – Patients and
deficits between: Neuropsychology correlated with carers both
1. Patient and tests: 71 more severe overestimated
carer on (PCRS) dementia performance of
questionnaire fictional patient
Table 5.1 (cont.)
180
Main results
2. Patient rating, on video.

and prediction Poor correlation
and postdiction between the
on cognitive tests: insight measures
of self, other and
fictional patient
Giovannetti et al. AD: 9 Cognitive 1. MLAT-S MMSE, GerDS No correlation No correlation Insight varied
(2002) VD: 18 deficits, ADL clinician rating Neuropsychology between insight between insight across error types.
PaD: 10 and naturalistic of errors in tasks tests: 22, 35, 36, 39, and severity, and depression No difference in
MD: 17 action errors 2. Discrepancy 60, 72–74 number of errors insight across
Controls: 10 between patient or test scores diagnostic groups
and carer on
questionnaires
(AQ-Dm, IADL)
Harwood and AD: 91 Cognitive and Clinician rated: MMSE – Association –
Sultzer (2002) functional Item 12 from HDRS between poor
deficits NRS (inaccurate NRS insight and less
insight item) hopelessness
Robert et al. AD: 60 Apathy Discrepancy MMSE – AD had less –
(2002) MCI: 24 (components: between patient NPI insight into
PaD: 12 emotional, and carer on IA emotional
Controls: 19 initiative, questionnaire blunting and
interests) (IA) lack of initiative
than MCI, PaD
Rymer et al. AD: 41 Memory and Discrepancy MMSE, CDRS Poor insight – Both poor insight
(2002) functional between patient FrSBe correlated with and disinhibition
deficits and carer on ADL more severe contributed to
181
questionnaire BIZ dementia carer burden, but
(Green et al., disinhibition
1993, above) contributed more
Howorth and AD: 18 Cognitive 1. Clinician BDRS No correlation – Poor correlation
Saper (2003) VD: 8 deficits, ADL, rated (Verhey between insight between measures
LBD: 2 general: et al., 1993, above) and severity of insight
MD: 4 sense of self, 2. Discrepancy of dementia. (see text)
behaviours between patient Only insight
and carer on assessed by
IADL and PSMS prediction
3. Discrepancy in correlated with
patient rating cognitive test
and prediction performance
on memory tests
4. Interview with
patient and carer
Vogel et al. (2005) AD: 36 Memory 1. Discrepancy MMSE, CDRS, FBI, Correlation Performance on No difference in
MCI: 30 problems between patient Neuropsychology between insight FBI (behavioural insight between
Controls: 33 and carer on tests: 22, 32, 36, and dementia changes AD and MCI.
questionnaire 43, 55, 75–78, severity (MMSE). associated with Poor insight,
(Michon et al. SPECT No correlation lesions in but only on
1994) between insight prefrontal cortex) discrepancy
2. Clinician-rated and executive correlated with measure correlated
categorical 4-point function insight but only with reduced rCBF
scale (Reed et al., on discrepancy in right inferior
1993) measure frontal gyrus
Abbreviations:
Patients: AAMI: Age-Associated Memory Impairment; AD: Alzheimer’s disease; Dep.: Depressive Disorder; HD: Huntington’s Disease; HT: Head Trauma;
CVA: cerebral infarction subjects; D: Dementia (aetiology not specified); LBD: Lewy Body Dementia; MCI: Mild Cognitive Impairment; MD: Dementias of
Notes to Table 5.1 (cont.)
182
Multiple aetiologies; MID: Multi-Infarct Dementia; MII: Memory-Impaired Individuals (not meeting criteria for AD); PaD: Parkinson’s Disease; VD:
Vascular Dementia.
Scales/Measures: ACAD: Assessment of Cognitive Abilities in Dementia; AMIS: Awareness of Memory Impairment Scale; AQ-D: Anosognosia Questionnaire-
Dementia; AS: Apathy Scale; BDRS: Blessed Dementia Rating Scale; BIZ: Burden Interview (of Zarit et al.); BMIC: Memory–Information–Concentration com-
ponent of the BDRS; BMS: Bech Mania Scale; BPEA: Performance of Everyday Activities component of the BDRS; BPRS: Behavioural Pathology Rating
Scale; CDRS: Clinical Dementia Rating Scale; COR: Cornell Scale for Depression; DBDS: Dementia Behaviour Disturbance Scale; DPS: Dementia Psychosis
Scale; DRS: Dementia Rating Scale; EMQ: Everyday Memory Questionnaire; FBI: Frontal Behavioural Inventory; FIM: Functional Independence Measure;
FrSBe: Frontal Systems Behaviour Scale; GDS: Global Deterioration Scale; GerDS (-rel): Geriatric Depression Scale (-relatives version); GQ: General
Historical and clinical
Questionnaire; HAS: Hamilton Anxiety Scale; HDRS: Hamilton Depression Rating Scale; IADL: Instrumental Activities of Daily Living Scale; IS: Irritability
Scale; MADRS: Montgomery and Asberg Depression Rating Scale; MLAT-S: Multi-Level Action Test – Short form; MMSE: Mini-Mental State Examination;
NPI: Neuropsychiatry Inventory Scale; NRS: Neurobehavioural Rating Scale; OAS: Overt Aggression Scale; PBQ: Psychobehavioural Questionnaire; PCRS:
Patient Competency Rating Scale; PLACS: Pathological Laughing And Crying Scale; PSMS: Physical Self Maintenance Scale; RBMT: Rivermead Behavioural
Memory Test; SCQ: Self-Consciousness Questionnaire; STC: Social Ties Checklist; ZA: Zung Anxiety Scale; ZD: Zung Depression Scale.
Neuropsychology tests: 1: Benton Orientation Questionnaire; 2: Wechsler Adult Intelligence Scale – Revised; 3: Rey Auditory–Verbal Learning Test; 4: Benton
Visual Retention Test; 5: Rey–Osterrieth Complex Figure Recall Test; 6: Multilingual Aphasia Examination; 7: Test of Facial Recognition; 8: Judgement of
Line Orientation; 9: Logical Memory from Wechsler Memory Scale (WMS); 10: Paired Associates from Wechsler Memory Scale; 11: Word Recall – immediate;
12. Word Recall – delayed; 13: Word Recognition – immediate; 14: Word Recognition – delayed; 15: Picture Recall – immediate; 16: Picture Recall – delayed;
17: Picture Recognition – immediate; 18: Picture Recognition – delayed; 19: Digit Span; 20: Verbal Span; 21: Spatial Span; 22: Verbal Fluency; 23: Continuous
Performance Test; 24: Alternating Sequence Test; 25: Go–No-Go Paradigm; 26: Alzheimer’s Disease Assessment Scale – ideomotor, ideational and construc-
tional praxis tests; 27: Visual Reproduction; 28: Right–Left Differentiation Test; 29: Spatial Relationships Test; 30: Word List Generation; 31: WMS;
32: Wisconsin Card Sorting Test; 33: Graphic Series; 34: Frontal Behaviours; 35: California Verbal Learning Test; 36: Boston Naming Test; 37: Controlled Oral
Word Association Test; 38: Block Design; 39: Clock Drawing; 40: Visual Form Discrimination and Face Recognition; 41: Simple Drawings; 42: 3-D Block
Design; 43: Trail Making Tests (A and/or B); 44: Simple Reaction Time; 45: Letter Cancellation; 46: Face–Hand Test; 47: Short Story Recall; 48: Modified
Card Sorting Test; 49: Sequencing Test; 50: Cognitive Estimates Test; 51: Buschke Selective Reminding Test; 52: Apraxia Subtest of Western Aphasia
Battery; 53: Token Test; 54: Raven’s Progressive Matrices; 55: Buschke Cued Recall Procedure; 56: Finger Tapping Test; 57: CERAD Word List Learning Test;
58: CERAD Constructional Praxis; 59: Mazes; 60: Similarities; 61: Maze Test; 62: CERAD Word List Recognition; 63: CERAD Verbal Fluency Test;
64: Vocabulary; 65: Information and Orientation from WMS; 66: Boston Diagnostic Aphasia Examination; 67: Corsi’s Block Tapping Test; 68: Orientation–Memory
Concentration; 69: Visual Span; 70: Frontal Assessment Short Test; 71: Hopkins Verbal Learning Test; 72: Boston Revision of WMS; 73: Goldberg Graphical
Sequences Test; 74: Semantic Probe Test; 75: Danish Mental Status Test; 76: Danish Adult Reading Test; 77: Stroop Test; 78: Design Fluency.
Howorth & Saper, 2003). One study found a significant correlation between poor
insight and severity of dementia only after controlling for depression (Smith C.A.
et al., 2000).
Given the vast amount of research carried out in this area (see Table 5.1), it is
worthwhile considering some of the factors that are likely to be contributing to the
continued lack of consistency in results. Most obvious of course is the employment of
different insight measures in the studies. As detailed above and indicated in Table 5.1,
such differences relate to how insight is assessed, who does the rating, how the rating
is expressed (dichotomies or categories or continuous ratings), the level of structure
and detail applied to the assessment as well as differences in the ‘object’ of insight, i.e.,
the aspect of the patient’s illness addressed by the insight measure. Clearly, the range
and types of differences that are involved would suggest that measures elicit somewhat
different aspects of insight and that this may make a difference to the results of corre-
lational studies. It is interesting that when studies employ a combination of different
measures of insight, results vary according to the measure of insight used. For exam-
ple, Sevush (1999) found only a small association between poor insight and more
severe dementia when using a patient-rated questionnaire but the same study found a
stronger correlation when using a patient-carer discrepancy questionnaire or when
using a clinician-rated measure. Similarly (but with contrasting results), Howorth and
Saper (2003) found no correlation between insight and severity of dementia when
using a clinician-rated measure and a patient-carer discrepancy questionnaire.
However, they found a correlation between insight and severity when using a discrep-
ancy method based on the patient’s prediction of cognitive test results.
When studies distinguish between various ‘objects’ of insight in their analyses,
then different correlations have obtained again. For example, Starkstein et al.
(1996) found that only poor insight into cognitive problems correlated with more
severe dementia, whereas there was no such association between insight into per-
sonality changes/interests and severity of dementia. Interestingly, the opposite result
was reported by Seltzer et al. (1997). They found that whereas there was no cor-
relation between insight into memory problems and severity of dementia, there
was a significant correlation between poor insight into social function, self-care
and dementia severity. It seems therefore that many aspects around the insight
measures are likely to be important contributors to the type of insight elicited and
hence determine the correlations obtained.
Apart from different insight assessment measures used in the various studies,
there are other likely factors contributing to the variability in results. Of particular
note is the complicated issue concerning the assessment of the severity and/or
stage of dementia. One of the most frequent measures used by studies to assess the
severity of dementia is the Mini-Mental State Examination (MMSE) (Folstein et al.,
1975). Whilst clearly this is a useful screening measure of global cognitive function
with high inter-rater reliability (Hodges, 1994), as a measure of dementia severity,

there are two main factors that need to be considered. Firstly, it focuses solely on
severity of cognitive dysfunction and consequently patients can have similar MMSE
scores but, nevertheless, very different behavioural and functional problems. In
other words, the severity of the disease may, arguably, relate not only to severity of
cognitive problems but also to problems posed by behavioural and psychiatric dis-
turbances. Secondly, because it is designed as a screening measure and one that can
be carried out relatively quickly, the MMSE does not assess focal cognitive deficits.
Consequently total scores may encompass a wide range of severity of actual cogni-
tive impairments. Some studies have used other or additional measures of severity
such as the Global Deterioration Scale (Reisberg et al., 1982) which attempts to
stage the dementia on the basis of behavioural and functional changes as well as
cognitive complaints. Thus severity or stage of dementia is measured according to
assessed behavioural problems. But, cognitive function is measured on the basis of
patient complaints and on difficulties in performing everyday tasks rather than on
a formal cognitive assessment. Other measures of severity of dementia have
included more detailed cognitive measures which capture focal as well as global
deficits and other behavioural assessments (e.g. Neurobehavioural Rating Scale).
The point, however, is that all these measures of severity pick out different aspects
of problems in dementia with emphasis placed on different disease profiles.
Consequently, patients with a range of ‘severity’ may in fact be represented in one
category or by one (or a range) score. Such difficulties in assessing severity of
dementia are also likely to be contributing to the variability of results found when
correlating insight with severity of illness.
A few studies have attempted to examine what happens to patients’ insight with
progression of their disease. Results of these studies, too, are variable. Thus, while
there is general agreement that patients’ insight seems to get worse over time, there is
less agreement concerning the interpretation of this in relation to progression of the
dementia process. Some studies claim that patients’ insight becomes worse with dis-
ease progression (Reisberg et al., 1985; McDaniel et al., 1995; Starkstein et al., 1997)
in that insight deteriorates with cognitive deterioration over time (i.e. insight cor-
relates with severity at both baseline assessment and follow-up review). Other stud-
ies, however, argue that whilst insight tends to fall over time, there is no specific
relationship between patients’ insight and the progression of their dementia as
assessed by cognitive deterioration (Vasterling et al., 1997; Sevush, 1999). For example,
Vasterling et al. (1997), found that although longitudinal progression of unaware-
ness of deficits took place (over 16 months), this was not related to the degree of
change in MMSE scores over time. Furthermore, the initial differences in the size of
patients’ awareness in relation to different aspects of the dementia process were not
sustained over time as awareness seemed to deteriorate regardless of the disease
domain. Other studies report mixed results suggesting that patients show partial
preservation of insight over time (Kiyak et al., 1994; Derouesné et al., 1999). For
example, in the study by Derouesné et al. (1999), a correlation was found between
poor insight and more severe dementia as assessed by MMSE at baseline but not at the
follow-up assessment 21 months later. On the other hand, patients did show a corre-
lation between worse insight and more severe dementia at both time points when
severity was assessed by ADL rather than cognitive deterioration. Several studies
report that some patients seem to maintain their level of insight over time (Kiyak,
et al., 1994; Weinstein et al., 1994) or even show increased insight over time (McDaniel
et al., 1995). Clearly the mixed results and the too few longitudinal studies make it
difficult to conclude much about the relationship between patients’ insight and
disease progression. The same problems concerning different measures of insight in
various studies apply also to interpretation of results. Likewise, the practical difficul-
ties of measuring severity/stage of dementia and its longitudinal changes in a sensitive
way are the significant problems in research of this kind (Vasterling et al., 1997).
5.2.4 Insight in relation to specific brain dysfunction

In an attempt to explore possible neurobiological mechanisms underlying the
impairment of insight in patients with dementia, studies have followed neurological
research (Chapter 4) and tried to examine the relationship between poor insight
and specific brain dysfunction, focusing particularly on possible frontal lobe path-
ology. Most work in this area has sought to correlate patients’ insight with their
performance on neuropsychological tests though a few studies have also examined
patients’ insight in relation to neuroimaging studies of brain function. In line with
the research on anosognosia and frontal lobe pathology, some studies specifically
examined the relationship between patients’ insight and performance on tests of
frontal or executive function. Table 5.1 shows that here again studies show some
variability in results. Several studies found that poor insight was correlated with
significant impairment on ‘frontal’ tests, such as the Wisconsin Card Sorting Test
(see Table 5.1), (Mangone et al., 1991; Michon et al., 1992; 1994; Lopez et al., 1994;
Ott et al., 1996a; Starkstein et al., 1997b). Loss of insight in patients with dementia
was thus proposed as being intrinsic to the pathological process underlying
dementia when this affected frontal lobe function. The study by Weinstein
et al. (1994) whilst not examining the relationship between patients’ awareness and
their performance on frontal tests, nevertheless, suggested that patients with poor
awareness presented with more behavioural disturbances suggestive of frontal and
paralimbic involvement rather than with impairments in reading, writing, calcula-
tion and visuospatial orientation indicative of posterior brain involvement. The
study by Smith C.A. et al. (2000) found a correlation between poor insight and
frontal tests only after patients were controlled for depression.
However, a number of other studies exploring the relationship between patients’

insight and performance on neuropsychological tests, including ‘frontal’ tests, have
failed to find such a correlation (Reed et al., 1993; Dalla Barba, 1995; Migliorelli et al.,
1995; Starkstein et al., 1995a; Derouesné et al., 1999; Gil et al., 2001; Giovannetti
et al., 2002; Vogel et al., 2005). A couple of studies have suggested that poor insight
in patients with dementia correlated with impairment of visuoconstructional skills
(Auchus et al., 1994; Ott et al., 1996a) thus implicating a role for right hemisphere
dysfunction as an underlying mechanism for unawareness. Some support for this
has been proposed by the few neuroimaging studies showing decreased perfusion
in the right hemisphere on single-photon emission computed tomography (SPECT)
in patients with poor insight (Reed et al., 1993; Starkstein et al., 1995a; Ott et al.,
1996b). At the same time, these studies did not show any correlation between
patients’ insight and their performance on the appropriate neuropsychological
tests. Likewise, Derouesné et al. (1999), using SPECT, found reduced perfusion in
the frontal cerebral regions in their patients with poor insight but no such correl-
ation between patients’ insight and frontal neuropsychological tests. Similarly,
Vogel et al. (2005) reported reduced perfusion in the right inferior frontal gyrus in
patients with poor insight but no such correlation is found between patients’
insight and frontal neuropsychological tests. Interestingly, they found this correl-
ation only held when insight was assessed using a discrepancy measure rather than
a clinician-rated categorical measure. Other studies have simply reported a non-
specific association between poor insight and performance on a battery of neu-
ropsychological tests (e.g. McGlynn & Kaszniak, 1991a, b; Correa et al., 1996;
Deckel & Morrison, 1996). The study by Starkstein et al. (1996) specified that only
patients’ insight into their cognitive problems correlated with impaired perform-
ance on neuropsychological tests whereas their insight into their behavioural and
personality changes showed no such correlation.
As summarised in Table 5.1, the variations in methodologies, including differ-
ences in insight assessment, types and numbers of patients involved, and the range
of outcome measures employed, all are likely to contribute to this mixed and
inconsistent picture concerning the relationship between patients’ insight and any
possible brain dysfunction.
5.2.5 Insight in relation to psychiatric/behavioural syndromes

Much work has focused on examining the relationship between patients’ insight
and depression. The basis for this exploration relates to the question of whether
impaired insight seen in patients, rather than being a manifestation of an intrinsic
disease process reflecting damage to specific neuronal systems, is perhaps better
understood as a psychological defence against the knowledge of having such a pro-
gressive destructive disease and its consequences. Thus, it could be hypothesised
that patients with greater insight into their condition would show more depressive
symptomatology whereas patients without insight would show little in the way of
affective change. Studies exploring the relationship between patients’ insight into
their dementia and levels of depression once again yield variable results (see Table
5.1). Many of the studies find no association between patients’ insight and depres-
sion (De Bettignies et al., 1990; Reed et al., 1993; Verhey et al., 1993; Lopez et al.,
1994; Michon et al., 1994; Cummings et al., 1995; Starkstein et al., 1995a; Ott et al.,
1996a; Derouesné et al., 1999; Zanetti et al., 1999; Giovannetti et al., 2002). However,
in contrast, several studies do report a significant correlation between patients’
insight and depression, with greater insight being associated with more depression
(Sevush & Leve, 1993; Feher et al., 1994; Seltzer et al., 1995a,b; Harwood et al.,
2000; Smith C.A. et al., 2000). In addition, other studies present mixed results
reporting either weak correlations between insight and depression (Feher et al., 1991)
or correlations that are specific in particular ways. Thus, the study by Starkstein et al.
(1996) only found correlations between insight into cognitive problems and depres-
sion, whereas no such correlation was obtained between insight into behavioural
and personality changes, and depression. Other studies have specified the type of
depressive symptomatology correlating with insight. Migliorelli et al. (1995) and
Starkstein et al. (1997a) did not find a correlation between patients’ insight and the
presence of major depression (DSM-III-R) but they did obtain a correlation between
patients’ insight and the presence of dysthymia. Similarly, Seltzer et al. (1995a)
reported a correlation between patients’ insight and depressed mood but not with
a depressive disorder.
Exploring the relationship between patients’ insight into dementia and depres-
sion is, however, complicated by additional problems which make interpretation of
results particularly difficult and which are also likely to contribute to the variable
outcomes outlined above (Table 5.1). Firstly, the question of the nature of depres-
sion in patients with dementia needs to be considered. The hypothesis that greater
insight is associated with more depression in patients with dementia is based on
the assumption (amongst others) that the depression in these patients is ‘reactive’
in nature, i.e. a consequence of the experienced disabilities resulting from having
dementia. Thus, empirical findings of an association between levels of insight and
depression could be interpreted as supporting the notion that impairment of
insight was the result of psychological denial on the part of the patient. It might be
argued that patients, unable to face the knowledge of having such a terrible condi-
tion, could deny (by means of various psychological processes) this knowledge. In
turn, this lack of knowledge would prevent patients from experiencing the distress
(and hence depression) that this knowledge would entail. The problem is, however,
that there is little evidence to suggest that depression in patients with dementia is
solely a reactive process. Most research indicates that depression, either as a disorder
or as a constellation of symptoms, represents a range of heterogeneous conditions

in relation to dementia and indeed to other neurological states, such as cerebro-
vascular disease, head injuries, multiple sclerosis, etc. (Lishman, 1998). Depressive
syndromes in the context of dementia may therefore represent not only individual
reactions to having the disease but might be ‘organic’ manifestations of the disease
process or lesion. They can also be coincidental (genetic or other vulnerability)
manifestations or indeed can be behavioural phenocopies of multiple origins
(Berrios & Marková, 2001). Thus, in the latter case, symptoms and signs whilst
resembling depression may manifest as a result of the dementia disease process but
without actually representing a depressive illness or syndrome. Furthermore,
somatic symptoms such as anorexia, fatigue, weight loss, insomnia, etc. have been
regarded as symptomatic of the dementia process rather than necessarily reflecting
a depressive disorder (Troisi et al., 1996). At present, however, it remains difficult
to discriminate between such syndromes on clinical or phenomenological grounds
but, nevertheless, empirical findings of association or lack of association, between
depression and patients’ insight, must be interpreted in this context.
Secondly, measures used to rate depression in dementia are also likely to con-
tribute to the variability of results. The issues here fall into several areas. Firstly,
there is the question of the validity of using depression scales in patients with cog-
nitive impairment given that cognitive dysfunction may affect the reporting as well
as the manifestation of depressive symptomatology (Feher et al., 1992). Secondly,
there is the issue concerning the choice of rating scales and, particularly, the deci-
sion around whether clinician-rated scales or self-rated scales are used. Several
studies have suggested that discrepancies in diagnosing depression arise when self-
rating scales of depression are compared with clinician or carer ratings of patient
depression. Most studies find that patients ‘under-report’ depressive symptoms
(Mackenzie et al., 1989), but according to some studies patients report more depres-
sive symptoms in comparison to clinician-rated diagnoses (Burns et al., 1990).
Other studies suggest a more complicated relationship between clinician ratings
and self-ratings depending on different patient groups (Sayer et al., 1993; Snow
et al., 2005). This raises questions concerning the nature of the depression that is being
elicited by the different instruments. Ott and Fogel (1992; Table 5.1), using both a
clinician-rated instrument (COR) and a patient-rated instrument of depression
(GerDS) found that as patients’ dementia became more severe (in terms of cogni-
tive dysfunction), then the clinician-based scale and self-rating scale showed more
divergent results. The authors concluded that self-ratings tended to underestimate
the presence and degree of depression in patients with dementia and that clinician-
rated instruments of depression would have greater validity in this population. A
similar result was obtained by Feher et al. (1992), who also compared results
using a clinician-rated instrument (HDRS) and a self-rating measure (GerDS),
finding that the latter was valid in mild to moderate dementia only. Nevertheless,
like Burns et al. (1990), they found that patients with worse memory complained
of more depressive symptoms. Most studies however report that patients complain
less of depressive symptoms as their dementia progresses (Reifler et al., 1982;
Mackenzie et al., 1989; Ballard et al., 1991). Thirdly, there is also the issue concerning
different contents included within various depression measures. Harwood et al.
(2000), e.g., suggested that one of the reasons for inconsistent results was that the
studies using measures which contained a significant focus on somatic or neu-
rovegetative symptoms as inherent to depression (e.g. COR, HDRS, DSM-III-R
diagnoses) reported negative findings, whereas studies using measures which
included more subjective expressions of depression such as sad mood reported
positive correlations between insight and depression. However, it is likely that there
are additional factors involved for, as Table 5.1 shows, studies which have used
measures including somatic items have also reported positive correlations (Feher
et al., 1994; Seltzer et al., 1995b) and similarly, studies using more subjective meas-
ures have reported no correlations (Derouesné et al., 1999; Zanetti et al., 1999;
Giovannetti et al., 2002).
Given such variable results, as well as the complicated issues around the nature
and assessment of depression in patients with dementia, some researchers suggest
that, rather than searching for associations between patients’ insight and a depres-
sive disorder, it makes more sense to explore the relationship between patients’
insight and depressive/anxious symptoms since these may be more representative of
reactive states. As Table 5.1 shows, studies by Migliorelli et al. (1995) and Starkstein
et al. (1997a) found that whilst patients’ insight did not correlate with major
depression, it did seem to correlate with dysthymia. Seltzer et al. (1995a,b) likewise
found that whilst insight did not correlate with depressive disorder, it correlated
with depressive mood. Several studies suggested that patients’ insight was associ-
ated with more anxiety (Verhey et al., 1993; Migliorelli et al., 1995; Derouesné et al.,
1999) and one study found an association between patients’ insight and feelings of
hopelessness (Harwood & Sultzer, 2002). Other studies have found no correlation
between patients’ insight and anxiety (Seltzer et al., 1995b). There are too few stud-
ies in this area, however, to draw firm conclusions.
Similarly, studies exploring other psychiatric and behavioural phenomena in
relation to patients’ insight in dementia have been few in number and again yield
mixed results (Table 5.1). One of the more consistent results reported by a few stud-
ies is of a correlation between poor insight and greater apathy (Ott et al., 1996b;
Starkstein et al., 1996; Derouesné et al., 1999; Robert et al., 2002). Nevertheless, in
a study exploring the prevalence and clinical correlations of apathy and irritability
in 101 patients with Alzheimer’s disease, Starkstein et al. (1995b) found no correl-
ation between apathy and insight. The association between insight and apathy has
been based on the speculation that both poor insight and apathy may share a simi-
lar underlying pathophysiological mechanism involving either frontal or right
hemispheric function. However, any conclusions concerning the relationship
between insight and apathy would be premature particularly given the variable
findings in relation to the correlations between patients’ insight and measures of
cognitive/brain function.
Likewise, attempting to link impairment of insight with brain mechanisms
putatively underlying psychotic symptoms in dementia, some studies have
explored the relationship between patients’ insight into dementia and the presence
of psychotic/behavioural symptoms (Table 5.1). These studies have also yielded
mixed results with some researchers reporting an association between poor insight
and the presence of psychotic symptoms (Mangone et al., 1991; Weinstein et al.,
1994; Migliorelli et al., 1995; Starkstein et al., 1996; 1997a), and others finding no
correlation between insight and psychotic phenomena (Lopez et al., 1994;
Harwood et al., 2000). Starkstein et al. (1996) found that the correlations between
insight and different psychotic symptoms varied according to the ‘object’ of insight
assessed. Thus, poor insight into cognitive problems was associated with the pres-
ence of delusions whilst poor insight into behavioural/personality problems correl-
ated rather with more mania and pathological laughter. Seltzer et al. (1995b) reported
a correlation between carer-rated irritability in patients and worse insight, and
similarly Starkstein et al. (1995b) found a correlation between patients with irri-
tability and poor insight. Once again, the too few studies carried out in these areas
preclude any definite conclusions. In addition, the variable methods used in assess-
ing psychotic/other behavioural features and the different inclusions within these
(e.g. delusions, misidentifications, mania, etc.) are also likely to contribute to the
overall inconsistent results in this area.
5.2.6 Insight in relation to other variables

A few other associations have been sought by some studies exploring patients’
insight into dementia. Of particular clinical importance has been the finding that
impairment of patients’ insight correlates with a greater perceived burden of care
on the part of patients’ carers (De Bettignies et al., 1990; Seltzer et al., 1997; Rymer
et al., 2002). Here again the results of these few studies are not straightforwardly
endorsing poor insight as a contributor to carers’ burden but they raise once more
the likely complicated nature underlying the relationship concerned. For example,
De Bettignies et al. (1990) reported on patients’ poor insight into daily living skills
as correlating with increased burden of care perceived by the patients’ carers. This
finding was not replicated by Seltzer et al. (1997) as they did not find a correlation
between patients’ insight into their self-care and carers’ burden. On the other hand,
they did obtain a correlation between patients’ poor insight into their memory and
greater carers’ burden. Thus, it is not yet clear what aspect of insight may or may
not be important in determining carers’ perceptions of stress and burden. Rymer
et al. (2002) found that whilst poor insight in patients (including insight into
memory and functioning) correlated with more carer burden, disinhibited behaviour
on the part of patients was a stronger contributor to such burden. Lastly, it should
be mentioned that isolated case reports found an association between patients’
insight and suicide risk (e.g. Rohde et al., 1995; Ferris et al., 1999), and one study
reported that poor insight into attention was a predictor of patients who stopped
driving (Cotrell & Wild, 1999). At this stage, such findings can only be considered
as possible indicators for further work and exploration.
5.3 Impaired insight/awareness into function in dementia
For the sake of completion, a brief mention should be made concerning the notion
of impaired insight or awareness into function/knowledge in patients with demen-
tia. As already discussed in Chapter 4, the concept of implicit memory has been an
area of research from the neuropsychology and cognitive psychology perspectives
in healthy subjects and patients suffering from amnesic syndromes. To reiterate
briefly, performance on cognitive tasks can be improved on the basis of specific
experiences (e.g. priming or skill-learning tasks) of which individuals can remain
unaware (Schacter, 1995). In other words, implicit memory focuses on the idea that
learning specific tasks can be aided by mental processes of which the individual has
no conscious awareness. Patients with dementia, like those with various amnesic
syndromes, have been observed to show impaired explicit memory but, at the same
time, to preserve their implicit memory (McGlynn & Schacter, 1989; Schacter, 1995).
This demonstrates that dissociations can occur between possibly independent
aspects of memory functioning. In other words, patients’ performance on specific
memory tests can be enhanced using priming without the patients being aware of,
or showing insight into, the mechanisms by which they are able to recall set tasks.
Similarly to patients with amnesic syndromes, researchers have reported that
patients with Alzheimer’s disease show dissociations between the various types
of implicit memory that is preserved. Thus patients can exhibit different impair-
ments in implicit memory which suggests that awareness at an unconscious level
may be disrupted. For example, the commonest finding with respect to Alzheimer’s
disease has been that priming for word-stem completion tasks (lexical and pic-
torial priming) is impaired whilst priming for motor tasks is preserved (Shimamura
et al., 1987; Burke et al., 1994; Russo & Spinnler, 1994; Schacter, 1995). The con-
verse, i.e. deficits in procedural, motor-related tasks and sparing of verbal-related
tasks, has been found in patients with Huntington’s disease (Heindel et al., 1989;
Butters et al., 1990). This difference in the specific type of preserved implicit
memory observed between patients with Alzheimer’s disease and those with
Huntington’s disease has been related to possible different psychologically and
neurologically distinct implicit memory systems involved in the diseases. Thus,
Butters et al. (1990) postulate that verbal and pictorial priming may be dependent
on the integrity of neocortical association areas which are damaged in Alzheimer’s
disease. On the other hand, the motor skill learning is likely to be mediated by the
corticostriatal system which in turn is damaged in basal ganglia diseases such as
Huntington’s disease. Similarly, Keane et al. (1991) reported further dissociation in
priming deficits in their study of patients with Alzheimer’s disease finding that ver-
bal priming was impaired but perceptual priming was preserved. This they linked
to possible neuronal mechanisms relating to dysfunction of the temporo-parietal
lobe underlying the former and preservation of function in the occipital lobe relat-
ing to the latter, in keeping with the Alzheimer’s disease process.
The question, however, of whether implicit memory not only represents a dis-
tinct memory system from an explicit memory system but is also itself constituted
by a number of distinct implicit memory systems continues to be debated. Whilst
the observations of dissociations between explicit and implicit memory and,
particularly, the double dissociations observed in implicit memory is a powerful
argument for the existence of multiple distinct memory systems (Heindel et al.,
1989; Schacter, 1995; 1999), the underlying assumptions behind the implicit/
explicit memory research need to be understood (Chapter 4). At the same time,
others have argued against a purely multiple memory systems view, proposing
instead other possible explanations for the experimental dissociations in memory
observed focusing more on the ways in which memory might be stored, retrieved
and contextualised (see Bauer et al., 1993).
Finally, the question still remains, as far as implicit memory or knowledge is
concerned, where does awareness itself fit in the models proposed? Clearly, the dis-
tinction between explicit and implicit memory has been formulated as the absence
of conscious awareness in the manifestation of the latter. This then raises further
questions concerning the nature of awareness as a mental structure, the extent to
which the different mental functions might be associated with different levels of
awareness, the importance of awareness at different times, whether mental func-
tions themselves are defined in some way by awareness, etc. As was emphasised in
Chapter 4, the concept of implicit memory, or memory without awareness, has
been defined and formulated in a neuropsychological and cognitive psychological
framework in which mental functions are viewed in terms of independent/semi-
independent albeit interacting modules. Within this structure, implicit memory is
elicited on the basis of very specific cognitive tasks. The question, however, of how
unconscious awareness or mental processing might relate to an overall structure or
concept of insight remains to be explored.
5.4 Conclusion
Empirical studies on insight in dementia yield mixed and inconsistent results. As in

other clinical areas this variability is in part the result of methodological differences
between studies such as differences in patient groups, in measures used to assess
insight, in evaluation of disease severity and in the assessments of other clinical vari-
ables. Measures developed to assess insight have been particularly numerous and
diverse. These measures vary in a wide range of attributes, including content, per-
spective, level of detail, complexity, how they are scored, who does the ratings, etc.
Consequently, they elicit phenomena or aspects of insight that are likely to be very
different. It is interesting to note that where studies have employed various measures
of insight concomitantly, different outcomes have been found in relation to the spe-
cific measures used, providing some empirical confirmation that different aspects of
insight/awareness are elicited by the different measures (Green et al., 1993; Derouesné
et al.1999; Sevush, 1999; Duke et al., 2002; Howorth & Saper, 2003; Vogel et al., 2005).
In addition, however, factors specific to the study of dementia itself present fur-
ther difficulties for the empirical exploration of insight. Firstly, dementia is an area
of clinical and research interest for a number of professional disciplines, including,
neurology, psychology, neuropsychology, psychiatry, medicine, etc. The study of
insight in dementia is thus particularly influenced by differences in disciplinary
approaches. Often, such differences relating to the specific conceptual framework
of the discipline are not made explicit and this is likely to contribute to some of the
confusion around the nature of the insight phenomenon under study.
Secondly, it is apparent from the reviewed studies that researchers refer to a multi-
tude of related terms and concepts. Terms, such as unawareness, lack of insight,
anosognosia, denial, etc. are used both in different ways and interchangeably.
Concepts underlying these terms are correspondingly variable. The meaning of
insight thus varies considerably in empirical studies and, again, such differences in
meaning are generally not made explicit. Consequently, the phenomena of insight
elicited on the basis of different concepts of insight will vary and likewise con-
tribute to the mixed results of studies.
Thirdly, it is evident that there is a wide range of ‘objects’ of insight assessment used
in studies exploring insight in patients with dementia. In other words, researchers are
assessing insight in relation to various aspects of dementia. This carries significant
implications for the meaning of insight in terms of the clinical phenomenon that is
elicited in each case (Marková & Berrios, 2001). This is an important issue and is dis-
cussed in detail in Chapter 7. In brief, however, exploration of insight into ‘dementia’
will elicit a different phenomenon of insight than exploration of insight into a ‘spe-
cific cognitive impairment’. This, in turn, elicits a different phenomenon from that
elicited by the exploration of insight into ‘ADL’ or ‘depression’, and so on.
Part II
Conceptual
So far, the chapters in this book have explored how, in clinical psychiatry, the
notion of insight has become conceptualised as an independent phenomenon, one
that not only could be observed (to different extents) in patients with mental illness
but one that could, moreover, be measured and related to other clinical and non-
clinical variables. We have seen how, in Western cultures, this demarcation of insight
as an independent variable became possible in the context of a number of factors
including, a background of philosophical/psychological thought encouraging self-
observation and self-understanding, changing ideas concerning the nature of
mental illness itself, and, an environment that fostered close clinical observation.
Then, reviewing the study of patients’ insight in various clinical areas, we have seen
that perspectives taken to understand and assess insight in clinical (and non-clinical)
populations have been quite different. In part, this seems to have occurred as a
result of diverse theoretical positions taken by the different professional disciplines.
In addition, however, and closely interlinked with this is the fact that the different
demands of the various clinical populations have determined to some extent the
approaches taken. This issue will be discussed in more detail later. However, it is of
interest to reiterate, that in general psychiatry it was the observation that patients
with mental illness could have insight that led to further work exploring this phe-
nomenon. In contrast, in patients with neurological/neuropsychological impair-
ments, it was the converse observation that determined approaches exploring
insight in this clinical group. In other words, the study of insight in patients in these
areas was approached from opposite perspectives. In the former it was the surprising
presence of understanding and in the latter it was the surprising absence of under-
standing that contributed to the different approaches taken in relation to these
patients. Apart from the differences in approaches to the study of insight between
the different clinical populations, we have also seen how within one clinical popula-
tion differences are evident in the way insight is conceived and evaluated. And,
common to all the clinical areas is the striking finding that studies exploring
insight in these patient groups have yielded mixed and inconsistent results when
attempting to relate levels of patients’ insight with other clinical variables.
From the work examined thus far, a number of questions seem to emerge. The
first question relates to the multiple approaches taken to the study of insight in
196 Conceptual
patients. What does this mean in terms of understanding the concept or structure
of insight? Can the different conceptions and measures of insight be related or uni-
fied in some way? Or is it simply the case that different phenomena are being
invoked sharing only a superficial resemblance with each other? Secondly, how can
the variable results of the studies on insight be explained? Why is it that despite
extensive empirical work, it is still not possible to conclude much about the pre-
dictive validity of insight in relation to mental illness or its relationship to either
the patients’ illness or to individual/environmental factors? While some of the
inconsistent results between studies exploring insight could be explained on
methodological grounds, i.e. differences in study designs, different patient groups,
different outcome measures, etc., I would argue that there has to be another import-
ant factor to consider here, borne out also by the other questions raised, and that
has to do with the concept of insight itself. Throughout my arguments so far, I have
emphasised the complexity of the concept, the difficulties in delineating its bound-
aries as well as its likely multidimensional structure.
Perhaps then, in order to start answering some of the questions raised so far, it is
important to examine the concept of insight in detail, to look at its conceptualisa-
tion and to identify the crucial issues for clarification. This section of the book
therefore focuses specifically on exploring the conceptual problems that arise in
relation to the study of insight. Chapter 6 examines the concept of insight from the
perspective of its likely nature. Specifically, it addresses the issues involved around
the various meanings of insight and their determinants and discusses the implica-
tions these have for the empirical study of insight. Chapter 7 focuses on a crucial
feature of insight, namely, its relational aspects. It explores the ways in which dif-
ferent ‘objects’ of insight influence the clinical phenomenon of insight that is
elicited and examines the implications this carries for the structure of insight.
Based on the issues identified in the preceding chapters, Chapters 8 and 9 go on to
develop a model for a structure of insight. Firstly, Chapter 8 argues, on theoretical
and empirical grounds, for a meaningful distinction to be made between awareness
and insight. Then, Chapter 9, on the basis of this distinction, proposes a model of
insight structure that accommodates the relational ‘object’ of insight assessment.
Thus, a framework is presented which allows the identification and definition of
specific insight phenomena for the purposes of future empirical work.
6
The conceptualisation of insight
In order to start unravelling some of the problems engendered by the mixtures of

terms and conceptualisations of insight apparent in the literature, it would make
sense to approach a concept of insight in terms of its possible structure and com-
ponents. For this purpose it is useful at this point to first of all make an explicit dis-
tinction between (1) the theoretical concept of insight and (2) the clinical phenomenon
of insight.
The former refers to insight as a whole, to a construct whose structure and compon-
ents can be theoretically defined. As such, it can accommodate the range of meanings
of insight that have so far been offered albeit within a complex, multidimensional
structure whose boundaries are wide and blurred. The latter, on the other hand, refers
to the clinical manifestation (or elicitation) of what necessarily can only be an aspect
of the concept of insight. In other words, the concept of insight is wider than the phe-
nomenon of insight but it provides the scaffolding against which specific phenomena
of insight can be delineated and understood. Making this distinction is important for
a number of reasons. Firstly, it helps to organise and clarify the various conceptual dif-
ficulties that are involved in the study of insight. Thus, it may help us to understand
specifically where problems may lie and what type of problems we are dealing with. In
turn, such understanding may help either by pointing towards appropriate ways of
addressing the different problems or by providing a space in which the contribution
of particular issues may be acknowledged. Consequently, this enables us to under-
stand more clearly the limits to which problems can be resolved and the necessary
underlying assumptions that may be involved. Secondly, whilst the distinction
between insight as a concept and as a phenomenon is artificial since both the concept
and phenomenon of insight are constructs and their relationship is not straightfor-
ward (see later), it allows us to translate in a more structured or systematic way from
the concept to those aspects of insight that may be manifested or elicited empirically.
In turn, this allows us to understand and devise measures of insight in terms of clearer
ideas concerning which components of insight are explored, in what way they may be
different from those assessed by other measures, and how individual components
might relate to an overall structure of insight.
This chapter therefore shall first explore issues relating more specifically to the
concept of insight, followed by those relating more specifically to the phenomenon
197
198 Conceptual
of insight. As implied above, this distinction is made for ease of analysis and it
should be understood that, in fact, in many respects the concept and phenomenon
of insight are interdependent. Hence, much of what is said about the concept will
apply to the phenomenon and vice versa. Throughout both sections, the chapter
highlights the implications of the issues raised for both the structure of insight and
for its empirical study.
6.1 The concept of insight: problem of meaning
The central question addressed in this section concerns the nature of the problems
which contribute to the complexities surrounding the concept of insight. In other
words, what is it about the concept of insight that gives rise to the difficulties we
have seen in defining it in a consistent way? Evidently, the different approaches to the
study of insight that have been reviewed share some things in common and, in vari-
ous ways, refer to some understanding or knowledge the individual has concerning
his/her condition. However, there are, as has also been clearly apparent, significant
differences. Such differences seem to present at various levels and need to be exam-
ined in some detail in order to allow us to develop a putative structure for insight.
The differences in meaning of insight can be usefully divided into two main types
or groups, namely, (i) problems of content and (ii) problems concerning the nature
of insight. Each of these will be explored in turn.
6.1.1 The meaning of insight: problems of content

We have seen how the content of the various definitions of insight offered in different
clinical areas, as well as within a particular clinical area, varies in a number of ways
including, specificity, breadth, complexity, type of judgements demanded, aspects
of condition involved, and so on. One of the most obvious types of difference to
emerge from the overall review, perhaps, lies in the breadth of definitions, i.e. the
ways in which the meaning of insight ranges from a narrow content at one end to
a broad or wide content at the other end.
In the narrow sense, insight refers to an awareness or recognition of a particular
condition or its aspect. This narrowness relates to the issue that the content of
insight is confined to a concept of knowledge in its most basic or unitary form, i.e.
as a simple perception of something with no further elaboration concerning the
nature or extent of this perception (Oxford English Dictionary, 2nd edition). It is in
this sense that the notion of insight was originally understood in the early nineteenth
century when it was first separated from the concept of madness and became, in its
own right, a subject for observation. Insight was simply awareness of madness, a
perception on the part of the patient that was given words in the acknowledgement
‘I am mad’ (e.g. Guislain, 1852). This narrow conception of insight changed,
199 The conceptualisation of insight
however, and broader views of insight are evident in the subsequent debates around
the notion (e.g. Société Médico-Psychologique, 1870) and in much of the later work
that focused specifically on this topic (e.g. Parant, 1888). Insight became more than
a perception of a madness state but was conceived as a knowledge of a madness state,
the knowledge that was understood in a wider sense than awareness or perception.
Hence, patients could have some knowledge about different aspects of their illness
and they could make judgements to varying extents about their condition and how
it affected them. This wider conceptualisation of insight meant that it was possible to
distinguish between various degrees of insight and patients, therefore, could be
described as showing different amounts and types of knowledge in relation to their
madness. In the context of increasing focus on quantitative research and the opera-
tionalisation of clinical variables, the empirical studies exploring insight in patients
with mental disorders highlight very clearly a similar range of definitions of insight
from the narrow to the wide (Chapter 3). Thus, the earlier studies view the patient’s
acknowledgement or recognition of being unwell as tantamount to having insight
(e.g. Eskey, 1958; Van Putten et al., 1976; Heinrichs et al., 1985) paralleling the narrow
conception of insight as awareness or perception of disturbance. At the same time,
the meaning of insight in such studies, whilst narrow in the sense of the awareness or
perception inherent in the definition, is broad in the sense of the lack of specificity
relating to the mental disturbance itself (see Chapter 3). Most of the studies where
insight is conceived in an all-or-none or categorical fashion imply a conception of
insight as a basic awareness or perception of a mental disturbance. Many of the more
recent studies, on the other hand, invoke a multidimensional conception of insight
where clearly the meaning of insight is broadened to a wider understanding of the
knowledge involved (e.g. Greenfeld et al., 1989; Amador et al., 1991; Marková &
Berrios, 1992a). This knowledge is wider in that it includes not just the perception
or awareness of some change in the patient but it also demands some judgements on
his/her part concerning the nature and consequences of the experienced changes.
Perhaps some of the widest conceptions of insight have been offered in the psy-
choanalytic literature (Chapter 2). Here, insight has been conceived as a much ‘deeper’
knowledge of changes in the self – deeper, in several senses of the term. Firstly, the
type or content of the knowledge itself is viewed as deeper, encompassing the under-
standing an individual has of his/her self in the context of life experiences and rela-
tionships together with the understanding of his/her motivations, the latter often
couched in terms of unconscious mental processes. Secondly, the way in which such
knowledge or insight is acknowledged is conceived as taking place at different levels
of understanding. In other words, distinctions are made between the levels at which
such knowledge is understood by an individual, e.g. cognitive, intellectual, emotional
or dynamic level (Reid & Finesinger, 1952; Bibring, 1954; Richfield, 1954). Thirdly,
possible reasons or motivations behind changes in insight are incorporated into
200 Conceptual
the concept itself. Denial in this context is a psychological coping response designed
to protect individuals from the consequences of having knowledge of their illness/
disabilities (Weinstein & Kahn, 1955). Thus, the concept of insight within this par-
ticular psychological framework is very much broader including knowledge not just
of particular experiences but of the way in which the self relates to them, absorbs
them and acts on them and understands underlying reasons and purposes.
In contrast, as has been emphasised in the work on insight in neurological states,
insight in the narrowest sense of awareness or perception has been exemplified
particularly by the original concept of anosognosia (Chapters 4 and 5). Perhaps
it is because of its derivation from the opposite perspective, namely, as the study
of the lack of insight or unawareness of a particular deficit/impairment (explored
in detail in Chapter 7), that the meaning of insight in this context has persisted
in the narrow, circumscribed sense of awareness, i.e. the perception (or lack of)
that something is wrong. Even with some broadening of this concept engendered
by the proliferation of empirical work, qualitative differences in awareness or
knowledge have been limited to knowledge of different aspects of the impairment
such as severity (Prigatano et al., 1986), change compared with previous ability
(Sherer et al., 1998a) or prediction of ability (Schacter, 1991). In other words,
the knowledge remains focused on different aspects of the actual impairment but
does not refer (in a comparable way to the conceptions of insight in general psych-
iatry or psychodynamic psychology) to knowledge of what the impairment means
for the self.
Captured within the range of breadths of meanings of insight are the other dif-
ferences between contents of definitions that were noted above. For example, striking
is the range of different types of judgements inherent to the various conceptualisa-
tions of insight, particularly as far as the more complex multidimensional definitions
are concerned. Thus, in addition to an awareness of some change, concepts of insight
include various judgements relating to the following:
1 an attribution of the change to pathology (e.g. Jaspers, 1948; David, 1990; Amador
et al., 1991);
2 social consequences of illness (Amador et al., 1991);
3 views concerning aetiology and likely recurrence (Greenfeld et al., 1989);
4 perception of changes in the self and one’s interaction with the world (Marková &
Berrios, 1992a);
5 need for medical treatment (McEvoy et al., 1989a; David, 1990; Amador et al.,
1991).
6 attitudes towards experiences (Soskis & Bowers, 1969; Cutting, 1978; Marks
et al., 2000);
7 comparisons with previous function (Sherer et al., 1998);
8 predictions/postdictions of performance on specific tests (Schacter, 1991; Correa

et al., 1996);
9 resemblance of own experiences to hypothetical cases (McEvoy et al., 1993b);
and many more.
All of these judgements represent aspects of knowledge, elaborated from the

perception of change, about what might be happening to the individual. The issue
here, however, is that these judgements are different from one another and that the
resulting differences in content of the concept of insight in the various definitions
offered may be important in terms of the phenomenon of insight subsequently
elicited.
Having re-examined some of the main differences evident in the content of the
various conceptions of insight, the next question is: What does this mean? How can
knowledge of such differences help in the formulation of a coherent structure for
insight? Earlier, it was claimed that identifying specific problems at different levels
would help to clarify some of the complexities surrounding the concept of insight.
We have established that contents relating to the concept of insight vary consider-
ably from narrow notions of knowledge or perception that something is wrong to
much broader knowledge incorporating a wide range of different sorts of judge-
ments as to what might be wrong, what this means for the individual and how this
affects him/her. The crucial problem that clearly emerges raised by these issues,
however, is one that concerns conceptual boundaries or limits. In other words, it is
apparent that the concept of insight, as defined by awareness and knowledge, has
contents whose boundaries are difficult to define and fix. Knowledge in a general
sense, by definition, cannot be demarcated easily and here, knowledge in the specific
sense of understanding about a particular condition and how it affects an individ-
ual is further complicated by the problems pertaining to the condition itself (par-
ticularly as far as mental disorder is concerned and how it is understood generally)
as well as factors relating to knowledge of the self. This can be illustrated by taking
schizophrenia as an example. Thus, when examining what it means to have knowl-
edge of schizophrenia, a multitude of questions arise, such as: To what extent might
a patient be expected to know about their mental disorder, even in fairly general
terms about its likely cause, course and prognosis (issues which may be difficult for
the clinicians themselves to answer)? What level of knowledge and information is
needed in order for an individual to be aware of having a mental disorder? Is it pos-
sible for a patient to have insight into having a mental disorder in a situation where
he/she does not actually have the relevant information concerning the mental dis-
order? What about awareness or knowledge concerning the individual components
or symptoms/signs that constitute the condition? Is it necessary for a patient to be
able to appraise accurately all his/her symptoms or is it enough to perhaps show
202 Conceptual
understanding of some? How many symptoms ‘correctly’ appraised would signify

insight? (And who determines the constituting symptoms/signs of a particular
mental disorder?) How ‘correct’ does the patient need to be in terms of judging the
severity of the condition affecting him/her? What degree of certainty concerning
his/her awareness or knowledge is necessary for an individual to have insight?
To what extent should an individual be able to assess the consequences of having a
particular condition or disability? Should this apply to all areas, or only some, of
his/her life? How much change should an individual be able to judge and relate
to his/ her self and functioning? How much knowledge should a person have of
his/her self and in which contexts? Which implications of having a condition should
be understood by the patient? Listing such questions may give the impression that
more questions are raised than answered by examining the contents of meanings of
insight. However, what these questions illustrate in common is the impossibility of
drawing a line encompassing a finite content to the answers. The theoretical concept
of insight cannot have a clearly demarcated border for the limits or extents of
different aspects of awareness or knowledge relevant to the individual and his/her
illness may simply not be possible to define.
6.1.2 The meaning of insight: problems concerning its nature

A fundamental question concerning the meaning of insight remains that surround-
ing its nature, i.e. irrespective of the contents of the concept, what sort of entity is it
that is understood by the concept of insight? There are different, though interrelated,
approaches to addressing this question. One way is to consider this question from a
philosophical viewpoint and, specifically, examine the concept of insight from an
ontological and epistemological perspective.
Thus, taking an ontological view of the concept of insight would be to conceive
this as a ‘real’ entity, as something that has an existence which, given its definition
in mental terms and captured as a mental phenomenon, would, by virtue of some
form of brain–mind mapping, be underpinned by a physical reality. However, trying
to then determine this existence in a meaningful way would entail exploration
around the definition of such a physical reality – whether this can be understood
in terms of brain circuits, receptors, molecules, etc., as well as attempting to address the
old question concerning the nature of the relationship between mental and brain
structures. Moreover, the question of the existence of insight as an independent entity,
i.e. as an entity independent of a physical (brain) reality would also have to be raised.
At this stage then, such an approach may not be particularly useful.
An epistemological perspective, on the other hand, would consider insight not
so much in terms of its possible existence as some real entity but in terms of the
legitimacy of the knowledge that is involved in its construction as a concept. In a
second sense, an epistemological perspective will also consider insight in terms of
what it can tell us about a particular aspect of the mind or the way in which indi-
viduals think and behave in regards to certain situations. In other words, taking an
epistemological perspective would mean that the ‘reality’ of insight as a structure is
defined not as an entity in itself but in terms of the validity of knowledge consti-
tuting it as well as through the way in which it helps to understand and organise
mental phenomena. Whilst this book takes an epistemological perspective in gen-
eral, this does not, at this point, help to clarify in a practical way the nature of the
concept of insight.
A somewhat different though related approach, therefore, and one that I propose
to take here, is to examine the nature of the concept of insight from the perspective
of clinical meaningfulness. The above distinction between ontological and epistemo-
logical perspectives is mentioned mainly because these perspectives are in some
ways reflected in the clinical approach. Specifically, I want to argue that the concept
of insight refers to a mental state and not to a mental symptom. This is a significant
claim because it carries important implications for understanding insight and for
empirical research in this area. These implications will be discussed later. At this
point, it is necessary to define the distinction between state and symptom.
By ‘mental state’ I am simply referring to a condition of the mind, or ‘the mental
or emotional condition in which a person finds himself at a particular time’ (OED,
2nd edition). For example, a mental state may comprise of mixtures of emotions/
feelings, thoughts, worries, daydreams, reflections, etc., any of which may assume
prominence at a specific time. By ‘symptom’ I am referring to an indicator of dis-
ease, i.e. ‘a phenomenon, circumstance, or change of condition arising from and
accompanying a disease or affection, and constituting an indication or evidence of
it; a characteristic sign of some particular disease’ (OED, 2nd edition, my emphasis).
For example, symptoms include a range of specific experiences which are perceived
as being out of the ordinary, uncharacteristic or even unexplained, such as pain,
low mood, fatigue, hallucination, etc. In other words, the main distinction between
the concepts I want to emphasise, and without making any assumptions concern-
ing ontology, lies in the crucial link with some form of pathology in the concept of
symptom. To repeat then, I would argue that it makes more sense to conceive the
nature of the concept of insight as a mental state and not as a symptom. Firstly,
however, are there grounds to this argument, i.e. is it the case that insight, or rather
lack of insight, is generally considered as a symptom, a phenomenon indicating dis-
ease, in the context of the empirical work that has been examined in this book?
6.1.2.1 Insight as a symptom?

It is of interest that, whilst a great deal of effort has focused on defining insight in
terms of contents of meaning, on the development of new multidimensional models
of insight and on the devising of instruments designed to capture those meanings
204 Conceptual
empirically, there has been little work specifically exploring the possible nature of
insight as a concept or phenomenon. In general psychiatry, there is some direct ref-
erence to the view that poor insight represents a symptom or feature of the mental
disorder itself but otherwise most of the evidence substantiating this view is indir-
ect. In terms of the direct evidence, the most obvious source, as has already been
mentioned, has been the large study described in the Report of the International
Pilot Study of Schizophrenia (World Health Organization, 1973), in which ‘lack of
insight’ is reported as the most frequent symptom found in schizophrenia. This
finding, contained in a table depicting relative frequencies of symptoms found in
patients with schizophrenia has, since then, been reproduced not only in various
textbooks of psychiatry (e.g. Gelder et al., 1996) but also in numerous subsequent
articles exploring insight in patients. Thus, much of the empirical work examining
insight in general psychiatry has been based explicitly on this assumption that
poor insight is a symptom (or sign) of schizophrenia (e.g. Carroll et al., 1999;
Weiler et al., 2000; White et al., 2000; Pyne et al., 2001; and many more). In add-
ition, some researchers have themselves been explicit in articulating this view, e.g.
Cuesta and Peralta (1994) suggest that ‘lack of insight could be a primary symptom
resulting directly from the schizophrenic process’ (p. 359) and reinforce this view
in subsequent work (e.g. Peralta & Cuesta, 1994; Cuesta et al., 1995). Similarly,
Amador et al. (1994) reiterate that ‘poor insight is best viewed as a symptom (or
sign) comprising multiple components’ (p. 827). Cuffel et al. (1996) consider poor
insight to be an ‘important manifestation’ of schizophrenia, and, Kim et al. (1997)
refer to lack of insight as ‘an inherent trait of schizophrenia’ (p. 117). Perhaps one
of the most explicit expressions of the idea that poor insight is conceived as a
symptom of the disorder is seen in the study by Mohamed et al. (1999) where they
say, ‘poor insight can be conceptualised as an expression of the disorder [schizo-
phrenia], much as hallucinations or delusions’ (p. 525). Similar assumptions con-
cerning the notion that poor insight is a symptom of the disease can be found, to
varying degrees of explicitness, in studies exploring insight in organic brain dis-
orders (e.g. Green et al., 1993; see Clare, 2004 for review) and other conditions
(Chapters 3–5). There are some exceptions (and qualifiers, see below) to this gen-
eral view concerning the nature of insight. One obvious exception is the perspec-
tive taken within psychoanalytic psychology where insight is viewed as a mental
state, one which, moreover, explicitly colligates emotions and thinking into a
whole specifically relevant to the person. However, in general as far as empirical
studies of insight into general psychiatric disorders and organic brain syndromes
are concerned, it becomes apparent that poor insight is ‘treated’ as a symptom of
the patient’s condition.
Moving on to some of the indirect evidence for this claim, this can be inferred
from a number of points arising from both the theoretical and empirical work on
insight reviewed in this book. First of all, as already mentioned, it is clear that there
has been little specific focus on examining the nature of insight as a concept/
phenomenon. In whatever way defined, insight has been referred to in general terms
as a concept, a phenomenon or a construct. However, these terms, whilst providing
a particular frame for the contents of the definition, do not say anything about the
nature of these contents in the sense of what sort of entity they might represent.
Thus, apart from the claims explicitly viewing poor insight as a symptom as
described above, little else has been said directly. In fact, it is fair to say that this
issue has tended to be disguised somewhat by some confusion engendered through
deployment of various allusions relating to this point. For example, the concept of
insight is discussed in terms of aetiology or mechanisms, i.e. focusing on processes
that might result in poor insight (e.g. Arduini et al., 2003; Drake & Lewis, 2003;
Rossell et al., 2003) or models/theories, i.e. structures or frameworks that might
help to explain poor insight (e.g. Birchwood et al., 1994; Lysaker et al., 2003;
Thompson et al., 2001) or perspectives, i.e. different ways of conceiving poor
insight (David & Kemp, 1997). In terms of such mechanisms or models or per-
spectives described, the nature of the concept of insight is indirectly addressed. As we
have seen in Chapter 3, in general psychiatric disorders these mechanisms/models
tend to fall predominantly into three groups so that poor insight is explained in
terms of: (i) organic/neurocognitive dysfunction (e.g. Lysaker et al., 1998a; Young
et al., 1998; Larøi et al., 2000) or (ii) psychological/motivational response to illness
or (iii) symptomatic, i.e. intrinsically linked to a disease process and hence associ-
ated with psychopathology (e.g. Collins et al., 1997; Smith et al., 2000) and many
researchers suggest that poor insight is a product of a combination of such
mechanisms (e.g. Vaz et al., 2002). In addition, some have suggested further possi-
ble models or perspectives, including personality factors and cultural or socially
determined attitudes (e.g. Johnson & Orrell, 1995; David & Kemp, 1997; White
et al., 2000; Clare, 2004). In the main, however, the underlying explanations for
poor insight have focused on the disease process itself either in terms of the
psychopathology of the illness or in terms of neurocognitive dysfunction. As
Amador et al. (1991) state clearly, ‘some forms of unawareness may stem directly
from the pathophysiology of the disorder’ (p. 128) and this view has been the prin-
ciple one on which the postulated mechanisms underlying poor insight are based.
These suggested models/theories underlying poor insight assume the link between
insight and disease and hence the nature of insight in these cases is construed as a
symptom or indicator of the disease process. Clearly, there are some qualifications
to this claim in that psychological defence mechanisms (or coping/motivational
factors) have also been invoked as possibly underlying poor insight and this would
then be counter to the notion that poor insight is a symptom of the condition and
instead would be seen as a response to the condition. Similarly, the suggestion that
206 Conceptual
social/cultural determinants may underlie the concept of insight would likewise go

against the idea that poor insight is simply a symptom of the patient’s condition.
Furthermore, there has been the occasional suggestion that insight is viewed as an
independent phenomenon from psychopathology or neurocognition (e.g. Jørgensen,
1995). Nevertheless, overwhelmingly, it is apparent that the research on insight in
general psychiatry has, in terms of the underlying models proposed, considered
poor insight in patients as a symptom or indicator of disease. Much the same has
been evident in work on insight in organic brain syndromes where, as we have seen,
the polarity between poor insight as intrinsic to the disease process itself and poor
insight as a psychological response has been more explicitly discussed (see Chapters
4 and 5). Here again, however, the main assumption underlying the models pro-
posed for unawareness of illness has been based on the view that poor insight results
from impairment of neurological or neurocognitive processes, i.e. poor insight is a
function of the disease process itself (Clare, 2004).
Apart from the types of models or theories proposed to underlie poor insight,
further indirect evidence suggesting that the concept of insight is generally viewed
and treated as a symptom comes from the general direction and methodology of
research taken in this field. As has already been alluded to in the earlier chapters,
much of the rationale behind studies examining the relationship between patients’
insight and clinical variables, such as severity or stage of illness, is dependent on
the view that poor insight is symptomatic of the condition (White et al., 2000). In
addition, much of the more recent focus of research on insight is in determining
brain structures underlying lack of insight by means of structural brain imaging
(e.g. Flashman et al., 2000; 2001) or correlating lack of insight with specific cogni-
tive dysfunction (e.g. Young et al., 1998; Drake & Lewis, 2003; Lysaker et al., 2003).
Rationale for this is clearly based on the view that lack of insight might represent
some sort of deficit or pathology and generally this has been linked to the illness
affecting the individual. Likewise, focus on exploring associations between poor
insight and specific neurocognitive dysfunction and neuroimaging in patients with
dementia (e.g. Ott et al., 1996b; Derouesné et al., 1999) has been based on the view
that poor insight is caused by the disease process itself. Finally, other indirect evidence
indicating that poor insight is considered as a symptom of the patient’s condition
can be seen in the way it is frequently evaluated. We have seen in the studies reviewed
that many different ways of assessing insight in patients have been developed.
However, it is apparent that many of the studies employ rating scales in which poor
insight is simply one of the ‘symptoms’ or variables assessed (e.g. Positive and
Negative Syndrome Scale (PANSS), Manual for the Assessment and Documentation
of Psychopathology (AMDP), Hamilton Depression Rating Scale (HDRS), etc.).
There are two points to consider about this. Firstly, there is no distinction between the
way in which the intensity or severity of poor insight is rated and the way in which
the intensity or severity of the other symptoms are rated. Secondly, the overall
severity of the condition is assessed by the total score on such instruments and con-
sequently, it is clear that poor insight contributes to the severity of the condition in
an analogous fashion to that of the other ‘symptoms’. In other words, whatever the
theoretical notion of insight might be, the issue is that in practical terms, the con-
cept is handled as another symptom.
6.1.2.2 Insight as a mental state?

In light of the above, the question is, whether it makes sense to consider poor
insight as a ‘symptom’ or neuropsychological deficit? Here I would argue for a
number of reasons that, in fact, it makes little sense to construe insight as a symp-
tom and that it may be more useful to view the concept of insight as referring sim-
ply to a mental state.
In the first place, it is difficult to reconcile the view of insight as a symptom with
some of the conceptualisations of insight as a multidimensional construct. Part of
the problem is that, in whatever way insight is framed, there has not yet been put
forward a theory of how these variously postulated components might relate to
each other. For example, David (1990), proposes a construct of insight that is based
on three distinct but overlapping dimensions (awareness of illness, the capacity to re-
label psychotic experiences as abnormal and treatment compliance). The question
is, what does overlapping dimensions actually mean? How do these proposed
components of insight overlap (i.e. in what form is this envisaged, is it that they are
part of a single structure or are they different components which share some prop-
erties, etc.?) and to what extent? Similarly, the multidimensional models of insight
put forward by others (e.g. Greenfeld et al., 1989; Amador et al., 1991) include a
number of component dimensions but again it is not clear how these dimensions
might relate to or interact with each other in a structural sense. In a telling state-
ment, Vaz et al. (2002) define insight as a ‘multidimensional phenomenon that
includes elements of a psychological, psychopathological, neurocognitive, and
interactional nature’ (p. 311). Clearly, the complexity of different dimensions
underlying insight is highlighted but the nature of the interaction, or overlapping,
between the dimensions has not yet been addressed. Likewise, David and Kemp
(1997) describe various distinct perspectives from which insight can be considered
and which may reflect different underlying mechanisms. However, the way in
which these perspectives may or may not relate to each other still needs to be
examined. Undoubtedly, there are major difficulties in trying to do so. The prob-
lem relates directly to the complexities around the concept of insight itself and this
has crucial implications for understanding insight and for its empirical study. In
other words, there is simply no theory available to bring together the possible
structural elements of insight and, consequently, while a conceptual definition of
208 Conceptual
insight is possible, the nature of insight as a whole remains obscure. However, as is

demonstrated by the range of perspectives from which insight can be explored
(David & Kemp, 1997), by the different types of dimensions that may constitute
insight (Greenfeld et al., 1989; Amador et al., 1991), and by the different forms of
judgements that may be involved (Marková & Berrios, 1995a, b), it is difficult to
conceive how all these elements together could be understood in the nature of a
symptom. This is not to take away any inherent complexity from symptoms them-
selves but to argue that the different forms or perspectives in which the possible
components of insight are conceived, i.e. their disparateness, suggest that, as a
whole, they relate more to a mental state than to a symptom signifying a disease
process or dysfunction.
It is possible of course that some specific aspect of the structure of insight may
be more directly linked to a disease process, and, theoretically, this can be envisaged
more clearly as regards the narrower concept of anosognosia or circumscribed
unawareness of a specific deficit (see Chapter 4). Indeed the same point is made
empirically by Freudenreich et al. (2004) who, on the basis of using the Scale to
Assess Unawareness of Mental Disorder (SUMD) in their study, suggest that, in
schizophrenia, symptom unawareness is most likely to reflect illness pathology
compared with other components of insight as determined by the SUMD, namely,
the judgements made around attribution of symptoms or willingness to accept
treatment. Similarly, recognition that social and cultural factors are important to the
views held by individuals concerning beliefs around mental disorders (Johnson &
Orrell, 1995; Lam et al., 1996; Chung et al., 1997), i.e. representing another per-
spective or dimension of insight, is much more indicative of reflecting a mental
state rather than being part of a disease process. Thus, the wider notion of insight
as knowledge and judgements or attributions concerning what is happening to the
individual cannot easily fit into a symptomatic picture of the concept. Again, however,
this highlights the need for a theory to bring together the components of insight
into some form of structure that can help clarify insight as a whole.
Secondly, apart from the fact that the components or dimensions of the concept
of insight are so different from one another, the types of contents of many of the pro-
posed judgements also are suggestive as reflecting more of a particular mental state
than a specific symptom of illness. For example, judgements relating to knowledge of
a condition and of its consequences to the individual are composite in nature and
themselves dependent on a wide range of subsidiary judgements affected by social,
cultural and personal factors most of which are difficult to conceive as determined
purely by illness/pathology. Moreover, as was established above, the problem of set-
ting specific or defined limits to the contents of such judgements again would be
more fitting with reflecting particular mental states rather than particular mental
symptoms. This can be illustrated by even cursorily comparing conventional
symptoms with the sorts of judgements that are involved in defining insight. Thus, a
complaint of feeling anxious or suffering pain or experiencing a hallucination are
symptoms which can be defined in terms of direct experiences on the part of the
individual. The patient may perceive a change in his/her state and the ensuing symp-
tom is an expression of the patient’s judgement concerning this change, his/her
description of the experience. In contrast, insight brings together a range of different
and disparate judgements in order to define the phenomenon; i.e. as we have seen in
metacognitive parlance, it involves judgements vis-à-vis the individual’s experience
as opposed to judgements involving the description of the experience. I suggest that
this would fit more with a mental state view of insight rather than a mental symp-
tom. There is, in addition, a further, more specific, point to consider here and one
that will be examined in more detail in the next chapters. Here, it is sufficient to say
that, by definition, any subjective experience described by an individual is dependent
on his/her awareness of this as a phenomenon for it would not be possible otherwise
to mark this out and apart from the underlying mental state. Consequently, it follows
that the experience of subjective phenomena is itself intrinsically linked with aspects
of the processes which constitute insight. This again implies that the concept of
insight has a wide, outreaching structure, one that would more easily be viewed as
underpinning a mental state than a symptom in the conventional sense.
Thirdly, the empirical work that has been reviewed both in general psychiatric
disorders and in organic brain syndromes shows convincingly the very mixed pictures
of outcomes between patients’ insight and clinical variables (Chapters 3–5). Thus,
some studies show an association between poor insight and more severe disease
(e.g. Verhey et al., 1995; Rymer et al., 2002; Vaz et al., 2002; Rossell et al., 2003) but
other studies disagree (e.g. Green et al., 1993; Lysaker & Bell, 1994; Chen et al.,
2001; Howorth & Saper, 2003). Similarly, some studies report an association between
poor insight and neurological lesion or neurocognitive dysfunction (e.g. Ott et al.,
1996a, b; Young et al., 1998; Lysaker et al., 2002) but, again, others find no such
association (e.g. Weinstein et al., 1994; Goldberg et al., 2001; Mintz et al., 2004). The
relationship between poor insight and disease factors can therefore at best be
described as variable. In other words, the rationale behind such studies, in terms of
viewing poor insight as an intrinsic feature of the illness itself, cannot be properly
sustained given the inconsistency of results. Again, this is suggestive of a wider con-
ception of insight as a mental state rather than a symptom.
Lastly, there is the issue of considering insight in so-called healthy individuals. Is
it the case, e.g. that healthy subjects are always insightful concerning experienced
events? Do such individuals always have full awareness and understanding about
their experiences and behaviours? It is difficult to argue for this being the case. In fact,
there is a great deal of evidence to suggest that in regards to ‘normal’ experiences and
behaviours, individuals show a range of insight or knowledge (Nisbett & Wilson,
210 Conceptual
1977; Wilson & Dunn, 2004). Leaving aside the question of value, i.e. whether full
insight is necessarily always beneficial to the individual, much work concerning
‘healthy’ individuals has focused on exploring possible mechanisms underlying the
different levels of insight or knowledge individuals have at different times and in
relation to different experiences. Just like in the work on insight in pathological
states, it has been postulated that both motivational and non-motivational processes
are important; the former are conceived in terms of both conscious and uncon-
scious mental processes and can be understood in various frameworks, e.g. psy-
choanalytic or self-deception (Fingarette, 1969; Haight, 1980); the latter are conceived
in more cognitive psychological approaches where unconscious mental processes
are viewed as intrinsic to the structure of the mind and consequently inaccessible
to introspection (Wilson & Dunn, 2004). The issue here, however, is that, irrespec-
tive of possible reasons and mechanisms underlying individuals’ insight into their
experiences, so-called lack of insight can be viewed as a common and normal and
sometimes adaptational phenomenon in healthy subjects. In this case, the question
of a link between lack of insight and pathology or illness simply does not arise.
This leaves us with the option that lack of insight in patients, conceived as a symp-
tom, represents a different phenomenon from lack of insight in healthy people.
Alternatively, and more plausibly I would argue that insight, is more usefully
viewed as a mental state whether this is in a healthy subject or in a patient with a
particular illness. Pathology or illness is only one factor that may affect an individ-
ual’s insight (or aspect of insight) but clearly many other factors will also be
important. In other words, as a mental state, insight will be independent from the
disease as such but interdependent with various factors, including disease, affect-
ing mental processes.
6.1.2.3 Insight as a dynamic mental state?

Viewing the nature of insight as a mental state rather than a symptom indicative
of disease carries a number of important implications. A mental state by its nature
is a dynamic process and will therefore fluctuate according to internal and exter-
nal changes. This means that some aspects of insight as a mental state may be
more stable or resistant to changes whilst other aspects may vary more readily.
Consequently, insight as a mental state will entail the consideration of a structure
for insight that would allow for such changes and that could generate hypotheses
concerning the likely stable aspects of the concept. This could be an important
area of empirical work. In addition, conceiving insight in terms of a dynamic men-
tal state can help to understand some of the results of empirical studies. For example,
longitudinal studies examining patients’ insight in relation to progression of
dementia report that patients’ insight generally seems to reduce over time (see
Table 5.1). Nonetheless, the same studies report that a proportion of patients show
improved insight over the time of the study (e.g. McDaniel et al., 1995; Derouesné
et al., 1999) and yet this finding tends not to be discussed, presumably because this
would be counter to the notion that poor insight is a symptom intrinsic to the dis-
ease process. Viewing insight as a dynamic mental state, however, could help to
explain such findings as the disease would only be one factor affecting insight and
other changes, such as for example increased information given to patients about
what they are experiencing, might contribute to insight held at a particular time.
The other main implication for empirical work, arising from the view that insight
may more usefully be considered a mental state, lies in the design of studies search-
ing for relationships between lack of insight and disease variables. This will be
explored in more detail later but essentially the issue lies in the question of local-
isation of lack of insight with brain changes or cognitive dysfunction. As a mental
state, it would make little sense to attempt to correlate this with structural brain
lesions. Efforts made at examining possible neurobiology underlying poor insight
are unlikely to be successful in relation to the mental state as a whole. Instead, it
would make sense to determine first perhaps those aspects of poor insight that
might be more directly related to a pathological process such as unawareness/
anosognosia in the narrow neurological sense and concentrate on likely associ-
ations there. Similar principles would apply to studies exploring poor insight as
inherent to the disease process. In turn, this would depend on revising the methods
developed for assessing insight and addressing explicitly the specific aspects of
insight to be explored.
6.2 The phenomenon of insight: problem of interpretation
Earlier, for ease of analysis, the distinction was made between the concept and the
phenomenon of insight, the former referring to the theoretical structure or mean-
ing of insight and the latter referring to that aspect of the concept that is elicited in
a clinical or empirical situation. It was emphasised that the concept of insight was
wider than the phenomenon as it would be unrealistic to expect to be able to elicit in
a clinical event the totality of what insight as a whole might encompass. However,
it was also stressed that this distinction is artificial and made simply to organise the
arising theoretical issues around insight and its empirical study. Therefore, it is
important to reiterate that the problems of meanings of insight, as discussed
above, likewise apply to the phenomenon of insight. If, as was argued, insight is
most usefully viewed as a specific mental state with wide, undefined borders to its
content, then similarly, the phenomenon of insight can be viewed as a particular
aspect of such a mental state. In addition, however, the phenomenon of insight raises
other more specific issues and problems which also need to be examined. Whereas the
focus of the problems raised in relation to the concept of insight was seen as problems
212 Conceptual
of meaning, here in this section, the focus of problems in relation to the phenom-
enon of insight can be best described as problems of interpretation.
Problems of interpretation emerge by definition. Thus, by virtue of defining
the phenomenon of insight as that aspect of insight that is elicited clinically, the
question of interpretation necessarily arises because of the participation of judge-
ment on the part of another individual with respect to the patient. This is import-
ant because of the contribution of this external judgement to the phenomenon
of insight itself. In other words, while, as was stressed earlier, the concept of insight
is wider than the phenomenon of insight, nevertheless, the phenomenon of insight
will include extra or additional elements relating to different forms of external
judgements that are involved in determining the phenomenon itself. There are
several aspects to consider in relation to this and it is worthwhile to briefly exam-
ine these and the implications they carry for understanding the phenomenon
of insight.
6.2.1 Interpretation in translation from concept to phenomenon

Interpretation is involved at one level in the translation of the concept of insight
into an empirical measure designed to capture this, or rather aspects of this. The
numbers and varieties of measures for assessing patients’ insight in general psychi-
atric disorders and organic brain syndromes have been illustrated in the previous
chapters and the differences between them highlighted. There are two issues that are
important here. Firstly, there is the question of the extent to which the measures
actually reflect the underlying concept of insight held by the researchers and, as was
seen in the earlier chapters, this varies considerably and seems to be partly depend-
ent on the degree of operationalisation employed. Secondly, however, it is evident
that researchers differ in their judgements concerning both the components of
insight (i.e. contents of measures) and the ways in which such components are
elicited (i.e. questionnaires, interviews, discrepancy measures, etc.). The phenom-
enon of insight that is captured by these instruments will thus vary accordingly. The
crucial point here is not simply that there are differences between the phenomena
obtained on account of the variability in measures used but that the source of these
differences has to do with the way in which the concept of insight has been con-
ceived. Consequently, the phenomenon of insight elicited will carry to some extent
the particular judgements and preconceptions of the measure’s originators. For
example, a measure of insight that determines insight on the basis of patients’
appraisals of and comparisons with hypothetical vignettes (e.g. McEvoy et al., 1993b;
Chung et al., 1997; Startup, 1997) demands different sorts of judgements on the
part of the patients than a measure of insight that is dependent on patients judging
their own mental states (e.g. Amador et al., 1994; Marková et al., 2003) or than a meas-
ure of insight that is dependent on degree of correlation between patient and carer
on views concerning various abilities (e.g. Green et al., 1993; Vasterling et al., 1997).
In each case, the types of judgements elicited from the patients have been influenced
by the specific conceptualisations of insight by the researchers and by the particular
ways these should be translated into an empirical measure.
6.2.2 Interpretation in clinician’s judgement

At a more explicit level, interpretation plays a special role in the direct elicitation of
patients’ insight. There are various ways in which this takes place. In the clinical situ-
ation where the patient’s insight is elicited by the clinician during an interview, by
means of structured or unstructured questions, there are three aspects to consider.
Firstly, there is the patient who interprets and articulates his/her experiences in a
particular way, i.e. there is the phenomenon of insight which emerges as the patient’s
construct. Secondly, there is the clinician who interprets the patient’s utterances
and behaviours, i.e. there is the clinician’s construct of the phenomenon of insight.
Thirdly, there is the interview situation itself, the dynamic interaction between
patient and clinician that is likely to contribute to the phenomenon of insight that
is elicited. The phenomenon of insight as the patient’s construct and the factors that
are likely to be important in this will be discussed more fully in Chapters 8 and 9
when the structure of insight is specifically addressed. Here, I just want to raise and
emphasise the likely contribution of the clinician and the clinician–patient inter-
action in determining the phenomenon of insight. In terms of the clinician, evalu-
ation of patients’ insight will be based on interpreting patients’ speech and behaviours
either in response to direct questions and/or indirectly, i.e. in the context of the psy-
chiatric interview as a whole. Unless the evaluation consists of a simple transcription
of patients’ answers to a pre-set scale or measure, then such interpretation will in
turn depend, to varying degrees, on specific individual clinician factors. These fac-
tors would include, e.g. the extent of the clinicians’ experience, their level of know-
ledge, their own conception of insight, their professional backgrounds, their attitudes,
biases, etc. Thus, the phenomenon of insight that is elicited will be constituted in part
by these individual judgements. For example, the same words spoken by a patient
may be interpreted by one clinician as the patient showing insight in that the
patient acknowledges he/she is mentally ill and willing to accept treatment, but by
another clinician as the patient showing little insight in that the patient is simply
repeating statements for motivational reasons in the knowledge that these will help
enable him/her to leave medical care. Much depends on the sort of rating of insight
that the clinician employs. Clearly the more ‘open’ such a rating is, e.g. where
insight is assessed as part of the normal mental state examination, or in some of
the categorical ratings seen in the empirical studies (e.g. Van Putten et al., 1976;
Heinrichs et al., 1985; Neary et al., 1986; Starkstein et al., 1993b) or where wide
anchor points are used in relation to structured evaluations (e.g. the insight items
214 Conceptual
on the Present State Examination), then the greater will be the contribution of
individual clinician factors to the actual phenomenon of insight that is elicited.
6.2.3 Interpretation in the clinician–patient interaction

In addition to the individual factors relating to the clinician which help to determine
the particular phenomenon of insight elicited, factors relating to the clinician–
patient interaction are also going to play a part in contributing to the end-of-line
construct. Such factors can only be speculative but are likely to shape the phenom-
enon of insight in different ways. For example, the degree to which rapport is
established, the extent to which patient and clinician relate to one another and the
mutual understanding that is experienced may determine the particular phenom-
enon of insight elicited. Thus, patients may in one situation feel able to express some
of their worries and concerns that relate to their understanding and knowledge of
what is happening to them but in another situation that same trust may not have
developed and their beliefs concerning their experiences may remain inaccessible to
the clinician. In addition, the clinician–patient interaction may have a more direct
contribution towards the constitution of the phenomenon of insight. In other words,
in the act of communication itself between the two individuals, patients’ subjective
experiences, particularly when these are inchoate and difficult to describe, may be
to some extent named and defined via the clinician (or whoever is communicating
with the patient). Thus, for example, half-expressed descriptions on the part of the
patient may be ‘helped’ to fit into the clinician’s terminology and in that sense
become crystallised into the ‘symptoms’. Making sense of these experiences there-
fore becomes an interactive process and the phenomenon of insight will contain
elements of this interaction.
6.2.4 Interpretation in comparative judgements

Ultimately, determining the phenomenon of insight in the clinical or research situ-
ation, directly or indirectly and irrespective of the measure chosen, will always
involve another important interpretative aspect, namely, the comparative judgement
that constitutes the final definition of the phenomenon. In other words, as others
have also emphasised (e.g. McGorry & McConville, 1999), the phenomenon of insight
is, in the end, a relative judgement, i.e. it is determined on the basis of the difference
between the clinician’s and the patient’s judgement concerning what is happening
to the patient. At its simplest, therefore, it is a measure of concordance between the
clinician and patient about the patient’s condition. Interpretation at this level
relates not just to the clinician’s perception of the patient’s condition but depends
on the clinician’s judgement of any discrepancy and is based on the assumption
that the clinician has the ‘correct’ appraisal. As was demonstrated from reviewing
the empirical studies exploring insight in patients with mental disorders and organic
brain syndromes, a wide range of measures have been developed to evaluate patients’
insight. The extent to which the judgement of discrepancy is exercised by the clin-
ician thus also depends, inter alia, on the type of measure used. For example, measures
of insight based on answers to general questions as to whether patients consider
themselves mentally or emotionally ill will demand different sorts of interpretation
of concordance from the clinician than measures which address a range of specific
aspects of the patient’s condition which perhaps narrow down some of the inter-
pretative elements. On the other hand, measures of insight which already rely on
discrepancies between patients and carers (e.g. Green et al., 1993; Smith et al., 2000)
will introduce additional interpretative factors, not only from the clinician who
evaluates the results but also from the family/carers who judge patients on various
problems/abilities. As was shown earlier, such judgements on the part of carers are
likely to be influenced by many factors, both individual and contextual, and may not
necessarily represent accurate appraisals (De Bettignies et al., 1990). The issue here,
however, is not so much about the accuracy or inaccuracy of such external judge-
ments of patients but about the fact that the final phenomenon of insight that is cap-
tured becomes a complex of subjective and ‘objective’ judgements and interpretations
whose individual components may not be easy to define. Similarly, where measures
of insight rely on discrepancies between patients’ appraisals of problems and per-
formance on specific tests (e.g. Anderson & Tranel, 1989), the assumption again is
that performance on the tests provides the ‘correct’ evaluation of patients’ abilities.
Nevertheless, the issue concerning the extent to which such tests actually reflect a sub-
jective experience of problems (generally couched in very broad terms) is a matter
of another type of interpretation. Different again is the interpretation of discrep-
ancy required in assessing insight on the basis of patients’ behaviours. In fact, as was
seen earlier (Chapters 3–5), there have been very few measures of insight focusing
on patients’ behaviours rather than speech but an interesting measure of insight in
patients with dementia was designed by Giovannetti et al. (2002) who observed
patients’ reactions to mistakes on ordinary tasks and on this basis made a judgement
of patients’ awareness. Clearly, the sorts of interpretations involved in this type of
appraisal will depend on different types of judgements and comparisons (i.e. judge-
ments concerning how a healthy subject might respond in a similar situation).
Apart from the type of measure of insight used, interpretation of discrepancy
between clinician and patient perception of problems will also depend on the ‘object’
of insight chosen for evaluation. In Chapter 5, the term ‘object of insight’ was intro-
duced to refer to the different aspects of dementia in relation to which insight was
examined (e.g. memory problems, activities of daily living, behavioural problems,
etc.).‘Object of insight’ as a general term referring to the relational aspects of insight
will be the focus of examination in Chapter 7. Here, the term is used to briefly illustrate
that different judgements are involved in the interpretation of discrepancies between
216 Conceptual
patients and clinicians according to which aspect of a patient’s condition is being

assessed. For example, a clinician evaluating patients’ insight into their ability to
dress themselves or into their hemiplegia will be able to make such a judgement based
on the discrepancy between patients’ claims and their abilities by means of direct
observation of that function or disability. On the other hand, a clinician evaluating
patients’ insight into their subjective experiences, such as depressed mood or hallu-
cinations, will have to make such a judgement based on an indirect or inferred assess-
ment of their experience. In other words, interpretations in these cases are made on
different types of data and consequently will involve different sorts of judgements
which in turn are likely to be influenced to greater extents by individual factors.
6.2.5 Phenomenon of insight: general implications

It can be seen from the above that the phenomenon of insight, referring to that
aspect of the concept of insight that is elicited clinically, presents some additional
problems that need to be considered in relation to its structure. Whilst, in definitional
terms, the phenomenon of insight can be viewed as the clinical manifestation of an
aspect of patients’ understanding concerning their condition, in structural terms
that understanding will be in part constituted by the interpretative factors belonging
to the clinician as well as, in an interview situation, by the interactive process itself.
The question is, however, what are the implications of understanding the phe-
nomenon of insight in this way for empirical research exploring insight in patients?
Firstly, it is important in terms of helping to appreciate more clearly the differing
capacities of measures of insight to capture different aspects of the phenomenon of
insight. In other words, even if all the possible external judgements likely to influence
the phenomenon of insight cannot be taken into account, the relative contribution
of different types and levels of interpretation involved when different insight
measures are used can at least be estimated. Secondly, understanding the clinical
phenomenon of insight in these structural terms (i.e. as a complex of patient–clinician
interacting judgements) will help in devising or choosing insight measures for spe-
cific purposes in research. For example, it may make more sense to use measures of
insight which capture relatively more of the patient construct than the complex
patient–clinician construct in studies which attempt to address possible neurobiol-
ogy underlying poor insight. Thirdly, much of the variability in empirical research
outcomes can also be explained more clearly in the light of this understanding for
it becomes evident that differences between instruments evaluating insight are
more than simply differences in the contents of some defined mental substance
owned by the patient. Instead, these differences reach out into a range of spheres
external to the patient. Consequently, the phenomena of insight captured by these
different measures are likely to contain quite diverse elements.
6.3 Conclusion
In order to address some of the complexities that have been raised around the study
of insight in the previous chapters, it is essential to examine in some detail issues
relevant to the conceptualisation of insight. For this purpose and reasons of analysis,
a distinction has been made between the concept of insight and the phenomenon of
insight. The concept of insight is defined as the theoretical structure of insight as a
whole whilst the phenomenon of insight refers to the clinical manifestation of insight
and, hence, reflects only an aspect of the concept of insight.
Examining the meaning of the concept of insight identifies two main areas of dif-
ficulties. Firstly, analysis of the range of definitions of insight in clinical and empir-
ical work indicates that it is the lack of defined boundaries to the various contents
that poses the main conceptual difficulty. In other words, the extent of the patient’s
knowledge or understanding of a condition that is required for insight, in terms of
detail of information, degree to which it affects oneself, the level of certainty, etc., is
difficult to demarcate clearly. Secondly, from a clinical perspective, exploring the
possible nature of the concept of insight shows that there is some confusion about
this in the literature. Most studies suggest that the concept of insight (or poor
insight) is viewed as a symptom or intrinsic feature of the condition affecting the
patient. On the basis of evidence provided here, however, I argue for a view of the con-
cept of insight as a particular mental state. In this sense, the concept of insight is, to
some extent, independent of the condition affecting the patient though its aspects are
likely to be affected by disease factors as well as by other non-disease-related factors.
Many of the multidimensional constructs of insight proposed in the literature would
fit in better with a mental state view of insight rather than a symptom view, partic-
ularly, since so far there has not been a theory put forward to help understand the
relationship of the various dimensions of insight to one another.
The view of the concept of insight as a mental state carries a number of impor-
tant implications including its conception as a dynamic process and one that is
likely to fluctuate under the influence of various internal and external factors. Most
importantly though, it carries implications for the way in which future studies on
insight need to be directed, especially as far as research on possible neurobiology is
concerned where more specified aspects of the concept of insight would need to be
determined.
Examining the phenomenon of insight identifies the main conceptual problem as
one of interpretation. In other words, as the phenomenon of insight is manifested
or elicited in a clinical situation, there will always be another participant/clinician
involved in making a judgement. Interpretation can be identified at different levels
including at the level of translation from concept to empirical measure, at the level
of clinician judgement and in relation to an interactive communicative context.
218 Conceptual
In the end, a judgement of patients’ insight is determined by the level of agreement

between patient and clinician (whether this is by interview, by questionnaires, or
discrepancy methods, etc.) and hence this is another form of interpretation.
In consequence of the interpretations that take place at different levels, the clinical
phenomenon of insight incorporates additional external elements that are not
within the concept of insight itself. The types and extents of such external compon-
ents will vary according to the measure of insight that is employed. What seems to
emerge from the analysis is that the phenomenon of insight cannot be considered
simply a particular identified ‘section’ of the concept of insight or cross-section of
a theoretically derived mental state. (The relationship between the concept and
phenomenon of insight is represented diagrammatically in Chapter 9.) Instead, it
must be viewed in the context in which it is determined, and, the external factors
that are likely to be contributing to its formation need to be acknowledged. These
factors themselves do raise practical problems because of their inherent nature.
Hence, whilst in theory factors relating to individual judgements (knowledge,
experience, attitudes, biases, preconceptions, mood states, etc.) and interactional
processes can be postulated as contributing to the determination of the clinical
phenomenon of insight, in an empirical situation they would be difficult to man-
age. Nevertheless, this should not detract from understanding that the phenom-
enon of insight carries these extra elements and is best conceived as a complex or
composite of the particular mental state of the patient, the various judgements on
the part of the clinician/interlocutor and their interaction.
7
The relational aspects of insight: the

‘object ’ of insight assessment
Following on from the previous chapter, in terms of examining some of the con-
ceptual problems underlying the meaning of insight, the focus in this chapter is on
another highly important aspect of insight, namely its relational nature. So far,
problems of meaning of insight have concentrated simply on the term itself. The
differences in the meaning of insight in regards to definitions varying in breadth,
detail, components, and otherwise, have been highlighted and difficulties around
specifying boundaries of the content of the concept have been identified. Likewise,
it has been argued that the nature of the concept of insight is most usefully regarded
as a mental state and consequently determined by multifarious elements of which
the mental disorder or condition affecting the patient is only one. Additional prob-
lems relating to the meaning of the phenomenon of insight have been raised on
account of the specific issues involved in the interpretation of a clinical state necessary
to the determination of the phenomenon of insight.
It has been apparent, however, both with respect to the exploration of insight in
different clinical disorders and with respect to the exploration of insight in a par-
ticular clinical disorder, that insight cannot be explored in isolation as some sort of
independent entity. Instead, the phenomenon of insight is always manifested or
elicited in relation to some aspect of the condition affecting the patient. In other
words, insight is a relational concept – or an ‘intentional’ concept in the sense of
Brentano (1874/1995). It can only be understood or expressed in terms of its relation
to something, be that a pathological state or a non-morbid experience. Thus, one
cannot have insight without there being something to have insight about and this
‘something’ has already been referred to as the ‘object’ of insight assessment
(Marková & Berrios, 2001). The ‘object’, therefore, refers to the particular mental/
physical state (e.g. mental symptoms, illness/disorder, neurological abnormality,
neuropsychological deficit, etc.) in relation to which insight is being assessed. The
essential point that will be argued in this chapter is that this relationship between the
phenomenon of insight and the ‘object’ of insight assessment is bi-directional (and
interactional). This means that, when exploring insight empirically, not only is it the
case that the ‘object’ of insight assessment needs to be specified but, and crucially,
the ‘object’ of insight assessment will, to a significant extent, determine the
219
220 Conceptual
phenomenon of insight that is elicited. This latter point forms the central issue in
this chapter and carries important implications for understanding the structure of
insight as well as for interpreting empirical studies on insight and for determining
future research in this area. In effect, this is saying that, different ‘objects’ of insight
assessments (e.g. delusions/hallucinations as opposed to mental disorder as opposed
to memory impairment, etc.) will determine phenomena of insight that are char-
acterised by essentially different clinical features. In other words, the phenomena
of insight elicited or manifested in relation to different ‘objects’ of insight assessment
will be structurally different from each other. Structure, in this context, refers to the
constitutive framework underlying insight, in terms of numbers and types of com-
ponents, their interrelationships and the rules (historical, theoretical, language based,
etc.) governing their interrelationships.
Before moving on to explore how different ‘objects’ of insight assessment might
exert their effect on the clinical phenomena of insight, the chapter first looks at the
importance of this claim in the context of current research work and in further
developing understanding around the meaning of insight at both the conceptual and
phenomenal levels. Next, the definition of ‘object’ of insight assessment will be exam-
ined in more detail and, finally, different ways in which the ‘object’ of insight assess-
ment may shape the clinical phenomenon of insight will be discussed.
7.1 Significance of the relational aspects of insight
At first glance it might seem that any discussion around the importance of, and
implications underlying, the relational aspects of insight is somewhat misplaced at
this point and would better belong at the end, after explication of the ways in which
objects of insight assessment may shape clinical phenomena of insight. However,
there is a two-fold purpose in dealing with this now and the second aspect relates
to presenting a rationale behind the examination of insight as a relational concept.
In other words, the significance of the relational aspects of insight is tightly bound up
in both the current assumptions made in empirical research as well as in the impli-
cations that are carried for future research and understanding of insight, and these
are difficult to disentangle cleanly from one another. Hence, from an explanatory
perspective, it is more useful to discuss the importance of the relational nature of
insight here.
What then is the significance of the relational aspects of insight? The fact that clin-
ically or empirically insight is explored in relation to different ‘objects’ of insight
assessment is not particularly surprising given the range and variety of conditions
affecting individuals. We have thus seen that, for example, insight has been elicited
in relation to different disorders (e.g. schizophrenia, bipolar affective disorder, depres-
sion, obsessive-compulsive disorders (OCD), dementia, head injury, cerebrovascular
221 The relational aspects of insight: the ‘object ’ of insight assessment
accident, etc.), in relation to different symptoms or groups of symptoms (e.g. delu-

sions, hallucinations, positive/negative symptoms of schizophrenia, depressed mood)
and in relation to different disabilities (e.g. hemiplegia, blindness, memory impair-
ment, behavioural disturbances, etc.). The various insight measures employed in
studies focus to different extent on the particular ‘object’ of insight assessment
chosen by researchers. What is being claimed here, however, is that such different
‘objects’ of insight assessment themselves determine, in part, the clinical phenom-
enon of insight elicited. Therefore, it would follow that the phenomena of insight
elicited in relation to different ‘objects’ are likely to be different, and, furthermore,
that these differences between the phenomena of insight may be important in the-
oretical and practical ways. Taking the various parts of this argument separately
and concentrating first on the point that different insight phenomena will be elicited
in relation to different ‘objects’ of insight assessment, it could be argued that this is
a self-evident claim. In other words, it makes sense for the relationship between the
phenomenon of insight and the ‘object’ of insight assessment to be viewed as
bi-directional in this way and that changes in the ‘object’ will necessarily affect the
manifestation of the phenomenon that is dependent on it.
In fact, however, it is clear from the research reviewed in this area that this issue
is not self-evident. Whilst, in general, studies may acknowledge that different phe-
nomena of insight are elicited on the grounds that different assessment measures
are used, there has been little serious consideration given to, firstly, the role of the
‘object’ itself in determining differences and, secondly, to the importance and impli-
cations of such differences. In practical terms, equivalence between insight phe-
nomena in relation to different ‘objects’ is, therefore, frequently assumed. This is
perhaps most obvious in the analogies made between anosognosia or unawareness of
specific neurological impairments on the one hand and poor insight into general
psychiatric disorders on the other (Chapter 3). Thus, as was seen earlier, the ration-
ale behind many of the studies searching for correlations between frontal lobe
and/or right hemispheric dysfunction and poor insight in schizophrenia and/or
schizoaffective disorder (e.g. Young et al., 1993; Lysaker & Bell, 1994; Flashman et al.,
2000; 2001 or mania (e.g. Ghaemi et al., 1996) or dementia (e.g. Michon et al., 1994;
Ott et al., 1996a, b; Vogel et al., 2005) is based on the finding that anosognosia in
relation to neurological states has been linked to frontal lobe dysfunction and
right-hemisphere damage (e.g. Bisiach et al., 1986; Starkstein et al., 1992). In other
words, it is assumed that ‘anosognosia’ as assessed in relation to an ‘object’ such as
‘hemiplegia’ and ‘impaired insight’ as assessed in relation to an ‘object’ such as ‘mental
illness’, both refer to a similar phenomenon. For example, Young et al. (1993) whilst
acknowledging the difficulties in determining a clear definition of ‘unawareness’ in
schizophrenia, unequivocally base their study on the possible association between
such unawareness and anosognosia. They define ‘unawareness’ in schizophrenia
222 Conceptual
as: ‘the phenomena in which individuals with long-standing schizophrenic symp-

tomatology state upon intensive questioning that they are not ill, do not have
symptoms or have no difficulties or abnormalities which they attribute to psychi-
atric illness’ (Young et al., 1993, p. 118). They view this as analogous to anosog-
nosia in neurological disorders and reiterate some years later: ‘in schizophrenia,
lack of awareness of illness may well derive from an organic substrate and may
itself be a neurocognitive deficit …’ (Young et al., 1998, p. 44). Mullen et al. (1996)
are particularly explicit in equating these phenomena: ‘The ability to re-label certain
mental events as pathological corresponds closely to the concept of anosognosia. …
The recognition by a patient of neurological symptoms is conceptually identical
with the recognition of psychiatric symptoms’ (p. 645, my emphases). Similarly,
amongst others, Amador et al. (1991), Amador and Gorman (1998), and Flashman
et al. (2001) argue for a strong resemblance between poor insight in schizophrenia
and anosognosia or unawareness of illness in neurological disorders.
Therefore, it is evident that much of empirical research on insight assumes
that the phenomena of insight elicited in relation to such different ‘objects’ as ‘neuro-
logical impairment’ and ‘mental disorder’ are, if not equivalent in form, then
at least sufficiently similar to warrant theoretical and empirical generalisations
between studies. On this assumption, therefore, it would follow that the phenom-
enon of impaired insight or unawareness in schizophrenia and the phenomenon
of unawareness in neurological impairments would share a common structure and
a common underlying mechanism. Similarly, the phenomena of insight elicited
in patients with dementia, where ‘objects’ of insight assessment tend to be particu-
larly variable (Chapter 5), tend, nevertheless, to be viewed as broadly equivalent
and hence as sharing a common structure and mechanism with those of insight
phenomena elicited in relation to other ‘objects’. It is this latter consequence
from the assumption of equivalence between insight phenomena in relation to dif-
ferent ‘objects’, i.e. the idea that common structures and mechanisms are likely
to underlie the insight phenomena, that is particularly important and that is
challenged here by the view that insight is inherently relational and hence the
phenomenon of insight will be directly shaped by its relational ‘object’. If it is the
case that the ‘object’ of insight assessment determines in part the clinical phenom-
enon of insight, it follows that phenomena of insight in relation to different
‘objects’ will be different accordingly. Depending on the nature of the clinical
features delineating the insight phenomenon in each case, differences between
insight phenomena could vary from minor surface characteristics to major clinical
differences. In the case of the latter, it is likely that such different insight phenom-
ena, consequently, would be underpinned by correspondingly different structures.
This, in turn, carries implications for different mechanisms or processes under-
lying insight in each case.
Clarifying the relational aspects of insight is, therefore, of theoretical and practical
importance. From a theoretical perspective, understanding the relationship
between insight and the ‘object’ of insight assessment should help to further deter-
mine the structure of insight both in terms of its overall structure as well as in terms
of structures underlying specific individual insight phenomena. From a more
practical viewpoint, clarifying the relationship between insight and the ‘object’ of
insight assessment may again also help to explain some of the inconsistent research
results and, furthermore, suggest appropriate methodological strategies for future
empirical work. In addition, from the research perspective, clarifying the insight–
‘object’ relationship is essential in order to address the assumption concerning
equivalence between insight phenomena. In particular, given the current focus on
brain localisation, it is vital that when exploring possible neurobiology of insight,
whether this is by means of neurocognitive function or neuroimaging or any other
way, the phenomena of insight chosen for investigation are of a similar structure.
7.2 The meaning of ‘object ’ of insight assessment
Before moving on to discuss the ways in which the ‘object’ of insight assessment
might shape and determine the phenomenon of insight, it is important to examine
in a little more detail the sense in which the ‘object’ of insight assessment is meant.
There are three aspects to this that need to be emphasised.
7.2.1 ‘Object ’ and ‘domain’

First, the ‘object’ of insight assessment has been defined as that aspect of the
patient’s condition in relation to which insight is assessed. We have seen that,
according to this definition, there is a wide range of ‘objects’ in relation to which
insight is evaluated. Thus, as demonstrated in previous chapters, patients’ insight
is assessed variously in relation to, for example, ‘mental illness’, ‘mental symptoms’,
‘neurological impairment’, ‘neuropsychological deficit’, ‘behavioural changes’,
‘functioning capacity’, and a great many more. The crucial issue here is that these
‘objects’ of insight assessment are not just different in terms of their content but
they are different in type. In other words, these ‘objects’ refer to different sorts of
aspects of the patient’s condition and, importantly, these aspects are not always
comparable in meaning. For example,‘mental illness’ cannot be considered as refer-
ring to a similar type of phenomenon as ‘memory impairment’ or as ‘ability to carry
out daily tasks’ or as ‘hemiplegia’, etc. This is, in part, a semantic distinction and, in
part, a natural distinction. The former relies on the fact that such ‘objects’ of insight
assessment belong to different categories of meaning (Ryle, 1949/1990). The latter
distinguishes such ‘objects’ of insight assessment on the grounds of basic differences
between the kinds of ‘objects’ or entities these represent. These distinctions will be
224 Conceptual
made clearer in the next section when the ways in which the ‘objects’ of insight deter-
mine phenomena of insight are examined in the light of such differences in semantic
category and specific kind. Here, it is necessary to simply make the point that ‘objects’
are different in type. This also serves to distinguish from another term frequently used
in relation to insight assessment, namely ‘domains’ of insight or awareness.
The term ‘domain’ of awareness has been used particularly frequently in the empir-
ical work on insight in dementia (Chapter 5). We saw how, in dementia, researchers
tended to distinguish much more specifically the different aspects of dementia in rela-
tion to which insight was elicited (e.g. Kotler-Cope & Camp, 1995; Vasterling et al.,
1995; 1997; Starkstein et al., 1996). Domain, however, in this context refers to the
particular feature of dementia that is being accessed. For example, domains of aware-
ness are delineated in relation to memory problems, problems with activities of daily
living, mood changes, etc. all of which are viewed as common characteristics of
dementia as a disease. Thus, the domain can be considered an area or particular func-
tion affected by the disease and, as such, different domains contain different contents
but will share the common feature of being a characteristic of the disease. The
‘object’ of insight assessment, on the other hand, refers to a wider notion for it
includes not just characteristics of the condition affecting the patient but also the
condition itself and indeed any non-disease-related areas. For example, in studies
exploring insight in dementia where insight is explored into patients’ experience of
the condition as a whole, rather than specific features such as memory problems or
language difficulties (e.g. Schneck et al., 1982), the term ‘domain’ would not apply
but ‘dementia’ would be the ‘object’ of insight assessment. Thus, the ‘object’ of
insight assessment embraces anything in relation to which insight is assessed.
Whilst it will include ‘domains’ of the particular disease affecting the individual, it
also refers to other and different aspects of the specific condition experienced by
the individual as well as to any states (not necessarily morbid or specific to a con-
dition) chosen by clinicians or researchers.
7.2.2 ‘Object ’ and phenomenon of insight

The second aspect, from which the ‘object’ of insight assessment needs to be
understood, is its intrinsic relationship with the phenomenon of insight. Indeed, it
is this intrinsicalness that forms the argument (see below) for the claim that phenom-
ena of insight are to some extent determined by the ‘objects’ of insight assessment. So,
what is meant by this intrinsic relationship between the phenomenon of insight
and its ‘object’? Earlier, it was pointed out that insight is a relational or intentional
concept, and that it is not possible to have insight without there being something to
have insight about. In other words, whatever the contents of the concept of insight
as a whole, i.e. the types of perceptions and judgements involved in the structure
of the concept, the mental state represented by the concept of insight is always
directed at something. This something or ‘object’ becomes the focus around which
the perceptions and judgements are formed. Thus, when patients’ insight is explored
in a clinical or empirical situation, an ‘object’ of insight assessment is necessarily
chosen, usually, though not always, by the clinician, in order that the phenomenon
of insight is manifested. Without the ‘object’ there simply would be no phenomenon
of insight to elicit. Consequently, in the manifestation or elicitation of the clinical
phenomenon of insight, the ‘object’ of insight assessment becomes inherent or intrin-
sic to the structure of the phenomenon. The separation that is being made here, in
this chapter, between the ‘object’ of insight and the phenomenon of insight, has to
be understood, therefore, as a clarificatory device to help emphasise the direction
from which the insight–object relationship is being explored and is not meant to
signify a ‘real’ separation as far as the structure of the phenomenon of insight is
concerned.
7.2.3 Patients’ and clinicians’ ‘object ’ of insight assessment

The third aspect of the ‘object’ of insight assessment that needs to be mentioned is the
issue of whether the clinician and patient are actually referring to the same ‘object’
when insight is being explored. In the previous chapter, problems of interpretation
were raised in relation to understanding the phenomenon of insight elicited clinically.
There, the focus was specifically on the phenomenon of insight as a whole (i.e.
without considering the relational ‘object’ independently) and the interpretative
issues involved were directed at ways in which the phenomenon of insight was con-
structed through the contributing judgements of clinicians (and others) as well as the
different influences of the types of measures used in determining patients’ insight.
The ‘object’ of insight assessment was only mentioned with respect to the point
that different types of ‘objects’ (e.g. ‘hemiplegia’ compared with ‘mental illness’)
presented different types of ‘data’ to the clinician and hence involved different levels
of interpretation when judgements were made concerning patients’ insight. (This
particular point is discussed in some detail in the next section.) However, the ‘object’
of insight itself (in a sense separate from the phenomenon) is also a matter of inter-
pretation and may not be assumed, necessarily, to be a point of correspondence
between the clinician and the patient.
For example, if we consider patients with dementia, they might be questioned
about their views concerning their memory problems. Whilst it is possible that both
patient and clinician consider the ‘memory problems’ as the ‘object’ of insight, it is
also conceivable that there may be a covert discrepancy in that patient and clinician
refer to different ‘objects’ of insight assessment. In this case, the clinician might,
in his/her head, have ‘dementia’ as the ‘object’ of insight assessment whereas the
patient might be focusing on ‘memory problems’. In perhaps a less obvious way,
even when clinician and patient both understand ‘mental disorder’ to be the
226 Conceptual
‘object’ of insight assessment, then differences between clinician and patient in their
understanding of what ‘mental disorder’ actually means may result in consideration
of different ‘objects’ of insight assessment. It is likely that the degree to which the
‘object’ is made explicit, as well as the individual understanding of what the ‘object’
means or represents, will both determine the extent to which there is agreement on
this between the patient and clinician. As was discussed earlier in regards to the
interpretative issues involved in the determination of the phenomenon of insight,
this is likewise an issue that carries implications for the empirical assessment of
insight particularly in relation to research. Again, this is something that simply
needs to be understood, or taken into some account, when the structure of the
phenomenon of insight is considered.
7.3 The phenomenon of insight as determined by the ‘object ’ of

insight assessment
Having highlighted some of the implications underlying the relational aspects of

insight, as well as having looked at the perspectives from which the ‘object’ of insight
assessment needs to be understood, this section, which forms the greater part of
this chapter, now addresses the claim itself, namely, that the ‘object’ of insight
assessment determines to some extent the clinical phenomenon of insight. The
questions therefore are, how can the ‘object’ of insight assessment exert this effect on
insight structure? And, in what ways will different ‘objects’ of insight assessment
determine different sorts of insight structures? Three possible ways are proposed
here: (i) ‘object’ as determined by discipline, (ii) ‘object’ as a semantic category and
(iii) ‘object’ as a specific kind, and each of these will be explored in turn.
7.3.1 ‘Object ’ as determined by discipline

The ‘object’ of insight assessment is, by definition, different in relation to different
professional disciplines. Within clinical psychiatry, for example, the ‘object’ of insight
assessment generally refers to ‘mental illness’ and/or ‘mental symptoms’, although,
as was reviewed earlier, often the distinction is not made (Chapter 3). In neurological
disciplines, the ‘object’ of insight assessment tends to refer to neurological abnor-
malities; for example, ‘hemiplegia’ or neuropsychological deficits such as ‘amnesia’,
‘dysphasia’, etc. In psychodynamic psychotherapy, the ‘object’ of insight may refer to
‘motivations’ and ‘behaviours’ as well as other ‘mental processes’, and, in cognitive
(Gestalt-influenced) psychology, the ‘object’ may be defined in terms of specific
problem-solving routines, and so on. The important issue here lies in the nature of
the differences between ‘objects’ as determined by discipline. This is because the dif-
ferences in the ‘object’ of insight assessment do not simply only reflect differences
of content representing the ‘object’, i.e. the content inherent to the subject matter
of the disciplines, but also reflect more profound differences in structure. In other
words, the ‘objects’ of insight assessment (and concomitantly, because of the nature
of the insight–‘object’ relationship, the conceptualisation of insight with respect to
the objects) are embedded in a theoretical background that itself is only under-
standable in terms of the historical development of the discipline. It is in virtue of
this particular difference between ‘objects’ of insight assessment in relation to different
disciplines that the ‘objects’ will exert their differential effect on the phenomenon
of insight. This is best illustrated by looking at some examples.
7.3.1.1 General psychiatry

In general psychiatry, current thought conceives mental disorders as arising from
a combination of individual (brain pathology, personality factors, psychological
processes) and external (social pressures, environmental stressors, cultural issues) fac-
tors. The clinician’s diagnosis of a mental disorder is based on an assessment of the
patient’s mental state in terms of identifying mental symptoms, signs and behav-
iours, contextualising these within the patient’s personal and background history, and
formulating this against the likely aetiological or triggering factors that may con-
tribute to both the development and the manifestation of the mental disorder. The
lack of clarity concerning pathogenesis of mental disorders (and consequently the
reliance on a classification of mental conditions that is based on arbitrarily deter-
mined patterns of symptoms/behaviours whose updating is governed by the particu-
lar theoretical and social drives of the time (Cooper, 2004)), however, together with
the lack of any biological markers comparable to those present in medical disorders,
means that the diagnosis of mental disorders is particularly complicated in the
sense of the types of clinical judgements that have to be involved. It is not the purpose
here to explore these but only to emphasise that these judgements are problematical
at different levels. Such levels include the elicitation of individual psychopathological
phenomena, the ways in which symptoms, signs and behaviours are expressed,
captured, conceptualised and named, the factors involved in putting these together
into diagnostic categories as well as the epistemic validity carried by the ensuing
symptoms and disorders (Berrios et al., 1995; Berrios, 2000; Berrios & Marková,
2002). It is these same symptoms, signs, behaviours as well as mental disorders as a
whole that constitute the ‘objects’ of insight assessment in general psychiatry. They
are therefore bound up in the same issues specific to this discipline in terms of the
ways in which judgements are formed and psychopathology is understood. Thus, they
incorporate a wide range of experiences, ones which vary in nature (e.g. subjective
experiences such as feelings of anxiety, uncertainty or complaints of fatigue, of
being watched, etc. and objective signs such as psychomotor retardation, thought
disorder, etc.) and content (e.g. abnormal perceptions, affective disturbances,
passivity phenomena, impairments/interferences with thinking, etc.). This variety
228 Conceptual
of experiences, forming these ‘objects’ of insight assessment, demands a broad view

of insight, and this is evident in the research reviewed earlier. Thus, whether referred
to in terms of ‘mental disorder’ (e.g. Wing et al., 1974; Kay et al., 1987),‘mental experi-
ences’ (McEvoy et al., 1989; Marková et al., 2003) and/or ‘mental symptoms’ (David,
1990; Amador et al., 1993), the ‘object’ of insight encompasses a broad structure
which in turn determines a broad conceptualisation of insight.
For example, taking ‘mental disorder’ as the ‘object’ of insight would entail con-
ceiving insight in terms of the particular way the disorder is conceived at the time.
This could thus include knowledge which ranges from notice of a change in the
self to some understanding of a few individual symptoms/signs to understanding
of the totality of the changes experienced as a result of the disorder and/or to
understanding of the details of the disorder and its likely causes, precipitants and
effects. In other words, ‘mental disorder’, however it is framed, whether this is in
terms of an illness, a change in the self or a sum of a number of symptoms/signs etc.,
will demand patients’ judgements that are wide or far reaching and of varying
complexity. Similarly, when a symptom such as ‘delusion’ is the ‘object’ of insight
assessment, this will demand a conceptualisation of insight that has to be based on
judgements which reach beyond the awareness of some pathological experience
and spread widely to form complex assessments concerning the nature of the experi-
ence. Therefore, in general psychiatry the ‘object’ of insight assessment itself deter-
mines a phenomenon of insight that is broad because it demands judgements
which are wide and complex involving not only assessment of the subjective expe-
rience but also determining its meaning in the light of general knowledge, past
experience, personal biases, etc. We have seen from the research in this area (Chapter 3)
that, in theory at least, insight has indeed been conceptualised in this broad sense
that encompasses, firstly, an awareness of patients’ varied experiences and, secondly,
some form of secondary elaboration of those experiences. The latter has been
variously defined by researchers as judgements (Jaspers, 1948), attitudes (Lewis,
1934), re-labelling (David, 1990), attributions (Amador et al., 1991), self-knowledge
(Marková & Berrios, 1992a), etc. Such conceptualisations of insight reflect the broad
judgements that are determined by the likewise broad nature of the ‘object’ of insight
assessment as a medley of mental and behavioural disturbance understood in a
context of socio-cultural factors.
However, the ‘object’ of insight assessment determines the phenomenon of insight
in an additional, more specific way. Mental phenomena and behavioural states
thought to represent mental disorders are identified and captured by means of
certain rules developed over time and themselves dependent on particular lines of
thought, beliefs about the nature of the ‘mental’ and the relationship with the ‘phys-
ical’, conceptualisation of psychological processes, definitions of morbidity or path-
ology, assumptions concerning classification of mental functions, and many more.
This structure underlying the rules of the diagnostic process forms the framework
of the clinical psychiatric discipline. Eliciting patients’ mental and behavioural
phenomena on the part of the clinician is dependent, therefore, amongst other
things, on a particular way of conceiving such mental and behavioural phenomena,
and their disturbances. This sort of understanding is, in turn, dependent on a tax-
onomy of mental function (and dysfunction) which is assumed a priori but is one
that has developed within the discipline, and, in the context of other influences,
over time. The question of whether such a taxonomy is ‘valid’, i.e. whether there is
correspondence between the conventional mental taxonomy with brain mechanisms
or functions, is not the issue here. Instead, the point here is that it is governed by the
concepts developed specifically in the context and function of clinical psychiatry as a
discipline and its antecedents. Mental and behavioural phenomena are identified,
classified and prioritised on the basis of such concepts. And it is thus that the ‘object’
of insight assessment, necessarily enmeshed within this framework, will elicit a phe-
nomenon that is likewise structurally bound to the same frame. Related disciplines,
whilst sharing some of the conceptual background, are, by reasons of diverse histor-
ies, foci, and functions, underpinned by different theoretical structures constituted
by different concepts and assumptions.
7.3.1.2 Psychoanalytic psychology

As was evident from the work examined in Chapter 2, in psychoanalytic psychology,
the concept of insight and its ‘object’ are much more firmly integrated within the
focus of the discipline itself. In other words, without necessarily being invoked as
such, insight in the sense of ‘deeper’ self-knowledge has formed the basis of psy-
choanalytic theory. (‘Deeper’ here refers to gaining access to whatever hidden or
‘unconscious’ knowledge is deemed relevant to explaining the patient’s psychopathol-
ogy.) The attainment of such insight is one of the therapeutic objectives of psycho-
analytic theory (Freud, 1973a, b). In contrast with general psychiatry, the concept of
insight, and the corresponding phenomenon, hold a much more prominent position
within psychoanalytic thought. The ‘object’ of insight here, tightly interwoven in
the specific language and conceptual background forming the framework of the
psychoanalytic discipline, refers, therefore, to some form of deeper knowledge of the
self – irrespective of whether or not this is couched in terms of ‘unconscious’ mental
processes. Consequently, the ensuing phenomenon of insight will require a differ-
ent conceptualisation – one that needs to articulate such deeper knowledge. As was
reviewed earlier, much of psychoanalytic work has focused on addressing the problem
of trying to capture such deeper knowledge. Insight in this context has been con-
ceptualised in terms of the ways in which this deeper knowledge is either acquired –
e.g. descriptive versus ostensive insight (Richfield, 1954), insight through clarification
versus insight through interpretation (Bibring, 1954), or understood – e.g. neutral
230 Conceptual
versus emotional versus dynamic insight (Reid & Finesinger, 1952), or manifested –
e.g. structured and/or re-created (Abrams, 1981; Sternbach, 1989; Blum, 1992). The
‘object’ of insight in psychoanalytic theory, therefore, determines a structure of the
phenomenon of insight in ways that are different from those shaped by the ‘object’
of insight assessment in general psychiatry. Furthermore, apart from these differ-
ences determined by content, theory (i.e. the particular conceptual framework
underlying psychoanalytic theory) and focus, the very nature of the ‘object’ of insight
assessment (i.e. the ‘deep’ self-knowledge) makes it difficult for the phenomenon of
insight to be elicited directly. Hence, the phenomenon has to be elicited indirectly
through the exploration of likely mechanisms or effects of attaining insight in the
individual. This carries specific implications for research in this area particularly as
far as developing insight measures is concerned (Chapter 2).
7.3.1.3 Neurosciences
Different from general psychiatry and psychoanalytic psychology is the conceptual
framework underlying the neurological and neuropsychological disciplines. Apart
from the differences in terms of content and focus of the work undertaken, and the
language and theoretical/conceptual frame on which this is based, one striking differ-
ence, already mentioned several times, is the perspective from which neurosciences
have developed interest in insight and awareness. For example, in contrast to general
psychiatry, it has been the dramatic loss of awareness or insight in the face of prom-
inent neurological abnormality that has stimulated interest and research on insight
in these disciplines. Consequently, conceptualisation of insight has been, from the
very beginning (apart from some qualified exceptions where motivational theories
have been proposed (Chapter 4, Weinstein & Kahn, 1955)), strongly linked to the
neurological abnormality itself. This has resulted in a phenomenon of insight that
has, analogously, a narrower content and much more clearly demarcated borders.
Putting this another way, the ‘objects’ of insight within the neurosciences disciplines
refer to the particular neurological deficits or neuropsychological impairments
that are evident to the clinicians. These neurological deficits and neuropsychological
impairments are themselves enveloped in the theoretical backgrounds of these dis-
ciplines. Therefore, in simplified terms the neurological and neuropsychological
understanding of such impairments and deficits (e.g. hemiplegia, amnesic syn-
dromes, dysphasia, etc.) is framed in a language (and concepts) relating to the brain
and to putative brain processes. Thus, neurological impairment and deficits are
explained in terms of brain localisation theories, either in structural (specific brain
lesions) or functional (neuropathology or neuropharmacology of specific brain sys-
tems) terms or structured on modular and information-processing models in which
neuropsychological processes are viewed as independent or semi-independent func-
tions loosely superimposed on brain structure (e.g. Mesulam, 1986; Schacter, 1990;
Stuss, 1991). The point here is that the ‘object’ of insight assessment, represented by
the neurological and neuropsychological impairments and deficits, is understood,
within these disciplines, in this particular ‘brain processes’ language. In turn, this
‘object’ of insight assessment determines a phenomenon of insight that is likewise
understood within this same theoretical structure. Hence, the phenomenon of insight
elicited in relation to the ‘object’ determined by the neurosciences disciplines, is a
structurally much narrower and more encapsulated phenomenon than that elicited
in relation to the ‘object’ of insight assessment in general psychiatry or psychoanalytic
psychology.
7.3.1.4 Cognitive (Gestalt) psychology

Gestalt-influenced cognitive psychology, in turn, focuses predominantly on cogni-
tive processes deemed to underlie intelligent behaviour (Chapter 2). As such, insight
has been conceptualised as a form of intelligent behaviour and the ‘object’ of insight
assessment consists of various specific problem-solving routines (Sternberg &
Davidson, 1995). In virtue of the different conceptual framework underpinning this
discipline, the phenomenon of insight determined by the ‘object’ of insight assess-
ment has to be very different from the phenomena of insight in relation to the dif-
ferent ‘objects’ from other disciplines. Interestingly, comparing Gestalt-influenced
cognitive psychology with cognitive neuropsychology offers another example of
the way in which the disciplinary background of the ‘object’ helps determine the phe-
nomenon of insight. In this instance, the ‘object’ of insight assessment, embedded in
Gestalt theory, determines a phenomenon of insight that represents, in a sense, the
opposite of the phenomenon of insight elicited by the ‘object’ of insight in cognitive
neuropsychology. This can be seen with respect to the phenomenon of ‘feeling of
knowing’. This phenomenon (implying some form of knowledge albeit at an inchoate
or unconscious state), within cognitive neuropsychology, is representative of some
degree of insight (Shimamura & Squire, 1986; Shimamura, 1994). On the other hand,
in Gestalt cognitive psychology, this ‘feeling of knowing’ is, within the context of
this discipline’s framework, specifically defined as a solution which is not insightful
(Metcalfe, 1986). This serves to illustrate how the concepts and foci underpinning a
particular discipline will structure the way in which ‘objects’ of insight are conceived
within it and these, in turn, will shape the specific clinical phenomena of insight
elicited therein.
7.3.1.5 Dementia
Whilst dementia does not refer to a particular discipline, it is mentioned briefly
here because of the special position it occupies in terms of crossing several profes-
sional disciplines and the implications this carries for the exploration of insight in
this area. In other words, in clinical work and research in dementia, many of the
232 Conceptual
clinical disciplines (e.g. general psychiatry, psychology, neurosciences, etc.) converge.

This has consequences for research carried out on insight in patients with demen-
tia. For example, it is likely that the mixture of disciplinary influences, in defining
the ‘object’ of insight assessment and eliciting the ensuing clinical insight phenom-
enon, will be an additional factor contributing to some of the variable outcomes pro-
duced in this area (Chapter 5). We have seen that, in research on insight in dementia,
many more ‘objects’ of insight assessment have been explicitly specified (e.g.
dementia as a whole, memory impairment, independent daily living skills, affective
symptoms, behavioural/personality changes, etc.). In turn, such ‘objects’ determine
phenomena of insight which are in line with the framework of their particular dis-
ciplines. This is, to some extent, reflected in empirical studies through both the termin-
ology used in referring to insight (e.g. lack of insight, unawareness, anosognosia,
impaired self-awareness/self-consciousness, etc.) and the diversity of approaches
taken to evaluate it (e.g. structured interviews, questionnaires, discrepancy methods,
direct observation, etc.). The issue here is that the contribution of the disciplinary
conceptual framework in determining the ‘object’ of insight assessment and hence
the phenomenon of insight elicited is particularly important to consider in an area
where different disciplines mix.
7.3.2 ‘Object ’ as a semantic category

Another important way in which the various ‘objects’ of insight are different from one
another is that they belong to different ‘semantic’ categories. This feature also influ-
ences the way in which ‘objects’ shape the phenomenon of insight. Above, it was
argued that ‘objects’ of insight assessment could be different on the basis of structural
differences relating to the theoretical backgrounds specific to individual disciplines.
Hence, the ‘objects’ would determine phenomena of insight that were likewise bound
up in the discipline’s conceptual frame. Here, the argument is that the ‘object’ of
insight assessment may be different by virtue of the difference carried by the seman-
tic category to which the ‘object’ belongs. In other words, the ‘objects’ of insight
assessment may refer to different sorts or types of terms, i.e. belong to different
categories of meaning in the sense of Ryle (1949/1990), and will, consequently,
determine phenomena of insight that will be structurally different. This again is
best illustrated by example.
The issue hinges on the validity of making comparisons between entities or
objects belonging to a different order of meaning. It has been noted in several
places, that some studies assume equivalence between the phenomena of insight
elicited in relation to different ‘objects’ of insight assessment. Of particular rele-
vance and importance in this regard has been the equivalence assumed between
the phenomenon of insight elicited in relation to ‘mental illness’ and the phenom-
enon of insight elicited in relation to ‘neuropsychological’ or ‘neurological deficit’
(Mullen et al., 1996; Amador & Gorman, 1998; Young et al., 1998; Flashman et al.,
2001, see above). As has already been demonstrated, this assumption has had
important consequences for the direction of research taken in these areas, particu-
larly, in terms of searching for a neurobiological explanation for impairment of
insight. This assumption of equivalence between insight phenomena in relation to
different ‘objects’ of insight assessment is, therefore, an important issue. Whereas
above this assumption was challenged on the grounds that ‘objects’ of insight
assessment, embedded in the specific conceptual backgrounds underlying differ-
ent disciplines (in this case, general psychiatry versus neurosciences), determined
phenomena of insight that were correspondingly structurally different, here the
argument against this assumption lies in the different order of meanings presented
by the ‘objects’. The terms ‘neuropsychological deficit’ and ‘mental illness’ are sim-
ply different with respect to the categories of meaning they represent. A similar
analogy can be made, for example, with the terms ‘flower’ and ‘nature’. The former
refers to a specific entity, directly observable and relatively easily demarcated with
clear boundaries. The latter may incorporate flower within its definition but refers
to much more than a collection of flowers and other such objects, and is not
directly observable nor easily demarcated. Perhaps another more relevant analogy
would be the difference between terms such as ‘nurse’ or ‘doctor’ and ‘the National
Health Service (NHS) system’. Whilst the former terms refer to specific entities or
subjects, directly observable and relatively easily described and defined, the latter is
clearly very much more than the sum of all the health professionals and resources
(and patients, etc.) contained within it. Instead, it includes within its meaning
the ways in which different parts of it work and interact, the politics involved,
the social issues, the hierarchies, and all possible structural elements and their
functional interrelationships. It is not directly observable and nor is it easily
demarcated.
Returning then to the terms ‘neuropsychological deficit’ and ‘mental illness’, we
are faced with similar categorical differences. The former refers to something that
is ‘objectively’ ascertainable in the sense that it is in principle determinable by a
third person either through direct observation or by means of specific tests and can
be relatively sharply demarcated. There is a one-to-one relationship between the
‘object’ (neurological or neuropsychological deficit, e.g. amnesia, hemiplegia,
dysphasia, etc.) and its determinable manifestation (e.g. poor memory, inability to
move limb, difficulty with speech). The term ‘mental illness’, on the other hand,
refers to a much broader construct and again, like ‘nature’ or ‘the NHS system’, does
not simply consist of a number of like subcomponents but embraces a wider struc-
ture that, in the case of ‘mental illness’, includes not only the signs and symptoms
of abnormal psychopathology (and the pathological aetiological factors) but also
the social, cultural, environmental and political determinants of the construct.
234 Conceptual
Direct observation and/or specific tests might not necessarily elicit it and bound-
aries of the construct are far from clear. There may be a one-to-one relationship
between some aspects of the construct (such as specific psychopathological signs)
and their determinable manifestation (e.g. psychomotor retardation, hallucin-
ations) but there is no clear one-to-one relationship between the construct as a
whole and its determinable manifestation. Indeed, as a construct in this wider
sense it would be illogical for it to have such a direct manifestation. Like ‘nature’ or
‘the NHS system’, it is simply not ‘observable’ in this sense and is only elicited or
determined (in the technical sense) by means of the specialised clinical judgements
exerted by health professionals. Moreover, many of the psychopathological, social,
cultural, political, etc., determinants fluctuate over time. Hence, this is not a fixed
concept and, as is clear from historical accounts, concepts of mental illness have
changed over the years and will continue to change (Berrios & Porter, 1995). Signs
and symptoms taken to indicate mental illness in one decade may not necessarily
apply in another decade. Similarly, they may differ from one culture to another or
even from one clinician to another.
In addition, whilst referring to a wide construct, the term ‘mental illness’ may,
from the perspective of the sufferer questioned about his/her insight, be confusing
or misleading in another sense, namely, with respect to the ‘illness’ component of
the term. Thus, although the clinician or observer are in a position where they may
be able to conceive ‘mental illness’ widely in terms of its theoretical determinants
and understand ‘illness’ in terms of morbidity, the patient may not experience
‘illness’ in the conventional meaning of the term. This means that there has to be
further distortion of the relationship between ‘mental illness’ as the ‘object’ and its
overt manifestation. This serves to highlight in another way the contrast between
the more direct one-to-one relationship between the ‘object’ of insight assessment
and its determinable manifestation that is present when the ‘object’ refers to a ‘neuro-
logical’ or ‘neuropsychological deficit’ and the lack of such a direct relationship
when the ‘object’ of insight assessment refers to a construct such as ‘mental illness’.
It seems, therefore, that there are important differences between terms such as
‘mental illness’ and ‘neuropsychological impairment’. These differences are not
simply those of content but relate to the way in which the referent is understood.
In other words, they belong to different categories of meaning. When ‘objects’ of
insight assessment refer to such terms, then likewise, they refer to different seman-
tic categories and in that sense they cannot be considered comparable (Ryle,
1949/1990). The phenomena of insight that are elicited in relation to such differ-
ent ‘objects’ of insight assessment, consequently, will be structurally different.
Thus, as is evident above, the phenomena of insight determined by these ‘objects’
must be constituted from different sorts of judgements, which are different not just
in terms of their content but in the types and complexities of judgements involved.
It follows from this that the phenomenon of insight elicited in relation to mental
illness may not be equivalent to the phenomenon of insight elicited in relation to
neurological or neuropsychological impairment.
7.3.3 ‘Object ’ as a specific kind

Apart from the influence of the disciplinary conceptual background and the
semantic category to which the ‘object’ of insight assessment belongs, ‘objects’ of
insight assessment will exert their effect on the phenomenon of insight in yet
another way, namely, one which depends on the type or kind of ‘object’ that is
involved. Whereas the previous line of reasoning is based on the distinction
between the semantic categories to which ‘objects’ of insight assessment belonged,
here the argument is that even when ‘objects’ of insight assessment belong to the
same category of meaning, an essential difference in the kind of ‘objects’ that they
represent, can determine important differences in the phenomena of insight. In
other words, ‘objects’ of insight assessment can refer to signs and symptoms of a
particular disorder (such signs and symptoms, therefore, belonging to a common
order of meaning, namely, characteristic features of a condition) and yet the nature
itself of these ‘objects’ (or signs/symptoms) can shape, in specific ways, the phe-
nomena of insight elicited in relation to them. It is useful to illustrate this point.
One of the most striking examples can be observed when comparing the sorts of
‘objects’ of insight assessment referred to by ‘neurological impairment’ or ‘neuro-
psychological deficit’ and ‘subjective mental symptoms’, and examining the respect-
ive phenomena of insight to which they relate (i.e. which they determine). Both
these kinds of ‘objects’ of insight assessment refer to characteristics of a disorder
that might affect a patient. Neurological deficit could refer to hemiplegia and con-
stitute a sign of a cerebrovascular accident and neuropsychological impairment
could refer to something like memory loss and this, in turn, might be a feature of
dementia or focal amnesic syndrome or a cerebrovascular accident, etc. Subjective
mental symptoms, on the other hand, could refer to, for example, hallucinations,
delusions, anxiety or depressed mood which in turn might represent features of a
mental disorder such as schizophrenia, schizoaffective disorder, bipolar affective
disorder, organic brain syndrome, etc. Both of these sorts of ‘objects’ of insight
assessment thus refer to particular features or signs and symptoms of a disorder.
However, there is an important difference in the kind or nature of the features they
represent. In the case of neurological/neuropsychological impairment, the nature
of the features referred to is that of an observable deficit or loss of function.
Something that was previously present as a normal or healthy function or ability
is now gone or simply not ‘working’ at its previous level. This applies to the ability
to walk, to move one’s limbs, to remember current and/or past activities, to be able
to speak and articulate clearly, etc. By contrast, in the case of subjective mental
236 Conceptual
symptoms, the nature of the features referred to is not that of a loss of function/
ability but that of an added or new experience. In other words, something that was
previously not present in the normal or healthy mental state is added to it such that
there is an experience of change. Even where that ‘addition’ results in a subjective
experience of loss of ability or function (e.g. loss of interest, enjoyment, motiv-
ation, etc.), the point is that there is, by definition, an experienced change, which,
whilst it may be qualitative or quantitative in nature, still represents an ‘addition’ to
a mental state experience. What then does this mean for the phenomenon of
insight elicited in relation to each of such ‘objects’ of insight assessment?
When the ‘object’ of insight assessment refers to an observable loss of function
or ability, the phenomenon demanded by such an ‘object’, has as its primary focus
the direct awareness of this loss or deficit. This seems to be the result of a combin-
ation of two factors, namely, the nature of the ‘object’ in this ‘loss of function’ sense
together with the traditional perspective from which this is explored (i.e. as has
been emphasised already, from the perspective of insightlessness or anosognosia) in
neurological states. In other words, because interest in patients’ insight into such
problems arose following the observations that patients seemed to be oblivious to
major impairments (Chapter 4), and because the impairments concerned are of a
relatively clearly defined and objectively evident kind, in terms of loss of ability (e.g.
loss of movement, loss of memory, loss of speech, etc.), this drives the insight phe-
nomenon to focus purely on awareness of the impairment in the narrow sense. If a
neurological loss of function/ability is clearly present, then awareness of not being
able to function in the normal way has to be the imperative focus. If a patient is not
aware of a deficit or disability, then that patient cannot make other judgements
about this. Consequently, the elicited phenomenon of insight has to be structured in
the narrow sense of awareness of the problem. Further judgements concerning the
nature and effects of the problem become irrelevant if the patient is simply not aware
of the loss of function in the first place. Clearly, as was also seen, with further clarifi-
cation around the different natures of the various neurological or neuropsychological
deficits, the phenomena of insight have widened somewhat to include judgements
concerning severity of deficits, impact on functioning, etc. (Sherer et al., 2003a, b), but
the core of the phenomenon determined by such ‘objects’ has necessarily remained
tightly bound to awareness in its narrow sense.
When the ‘object’ of insight assessment refers to ‘subjective mental symptoms’, the
phenomenon of insight demanded by such an ‘object’ has, by definition, a different
structural focus. It is a truism to say that individuals will be aware of ‘subjective
mental symptoms’ (e.g. hallucinations, delusions, depressed mood, preoccupations
with worries, etc.) because that is inherent to the definition of ‘subjective’. Patients
may either complain spontaneously of hearing ‘voices’, of being filmed by the govern-
ment, of feeling low in mood or sad, of being constantly worried by something,
etc., or these subjective phenomena may be elicited following direct or indirect

questioning. Whichever way such phenomena become apparent, the issue is that
awareness of them is to some extent part of their manifestation as symptoms.
Clearly, however, the phenomenon of insight in relation to these mental symptoms
is not considered to consist simply of their presence as elicited or spontaneously
offered. Instead, the phenomenon of insight in relation to these mental symptoms is
considered on the basis of the sense that patients make of such symptoms. In other
words, insight is focused on whether, for example, patients consider the voices in
their head to be pathological or normal, or represent some form of external influence.
Similarly, insight is focused on whether patients consider their low mood to be
pathological, a normal state they have always been in, the result of some real or
imagined misdemeanour and whether it has any consequence to their ability to func-
tion or relate to others, etc. Thus, awareness of the presence of these mental symp-
toms cannot be viewed as a phenomenon of insight in a comparable way to that of
awareness of the presence of a neurological deficit. Instead, ‘subjective mental
symptoms’ as ‘objects’ of insight assessment demand a different focus for the phe-
nomenon of insight. This focus has to do with the sense that individuals make of
these subjective symptoms, i.e. the judgements that are made concerning their
nature and meaning, the understanding that is held about their morbidity as mental
experiences and wider assessments concerning their effects on the individual. As
an ‘object’ of insight assessment, therefore, ‘subjective mental symptoms’ demand a
level of awareness and judgement beyond that demanded by the ‘object’ of insight
assessment when this is a ‘neurological/neuropsychological deficit’. Consequently,
‘unawareness of a mental experience’ in an analogous sense to ‘unawareness of
a neurological deficit’ has to be conceptually different from ‘unawareness of the
nature or morbidity of a mental experience’.
The ‘object’ of insight assessment, in terms of its nature or kind, therefore, is also
important in shaping the clinical phenomenon of insight. The way in which this
seems to happen, or means by which the phenomenon of insight is driven or deter-
mined by the specific nature of the ‘object’, is, however, clearly complicated by the
interplay of various dichotomies relating to the manner in which the nature of the
‘object’ is characterised. These have been raised at different points but it may be help-
ful, for the sake of clarity, to identify them explicitly.
7.3.3.1 Subjective–objective dichotomy

This is perhaps the most important dichotomy, which makes a distinction between
‘objects’ of insight assessment that are primarily identified by the patient (e.g. com-
plaints of pain, fatigue, low mood, hallucinations, fears, etc.) and those that are
primarily identified by an external individual, professional or other, by means of
observation or tests (e.g. psychomotor retardation, thought disorder, disinhibition,
238 Conceptual
inability to move limbs, comprehension difficulties, etc.). This is a qualified distinc-

tion in that the two polarities are not mutually exclusive. For example, patients who
complain of hearing voices may be ‘observed’ to be talking to someone in an empty
room, or patients who complain of low mood may appear sad and tearful, and those
worrying about persecutors may surround themselves with weapons, and so on.
Thus, all such subjective experiences may result in ‘objective’ inferences made by
clinicians that patients are hallucinating, are depressed or suffer from persecutory
delusions. Similarly, patients unable to move their limbs or showing psychomotor
retardation or having problems with their speech and thoughts may well also com-
plain of these difficulties and thus incorporate a ‘subjective’ element to the ‘objective’
signs. The issue here, however, is that some symptoms (to which ‘objects’ of insight
assessment refer) are generated by the individual/patient concerned and are not
accessible in the direct sense by another person while other symptoms/signs are mani-
fested indirectly (irrespective of how these may be interpreted by the patient), in an
‘objectively’ identifiable manner.
As we have seen, when the ‘object’ of insight assessment refers to symptoms which
are primarily ‘subjective’, the resultant phenomenon of insight will have a very direct
relationship with the ‘object’ or symptoms themselves. Thus, to reiterate, in the
articulation of subjective complaints, individuals are, by definition, forming judge-
ments on the basis of whatever it is they are experiencing. In the process of expressing
such ‘symptoms’ (or ‘objects’ of insight assessment), individuals make basic judge-
ments concerning the nature of such experiences and, therefore, these are intrinsic-
ally connected to the core processes involved in the formation of insight itself. When,
on the other hand, ‘objects’ of insight assessment refer to ‘objective’ symptoms/
signs, then the resultant phenomenon of insight will not have this same direct rela-
tionship with the ‘object’. Instead, the phenomenon of insight will be dependent,
firstly, on the extent to which the patient experiences the ‘objective’ sign in a subject-
ive manner (i.e. a core awareness on the part of the patient), secondly on the clini-
cian’s judgements and thirdly to a much greater degree on the discrepancy between
patient and clinician judgements. The structures of the insight phenomena deter-
mined by ‘subjective’ mental states and those determined by ‘objective’ signs must,
therefore, have important differences in core constituents.
7.3.3.2 Negative–positive dichotomy

Another distinction between different kinds of ‘objects’ of insight assessment is
based on whether the ‘object’ refers to a negative symptom/sign, i.e. an absence of
a normal experience, such as loss of function or ability in hemiplegia or amnesia,
etc., or whether it refers to a positive (in the sense of something added rather than
in the sense of positive content) experience, i.e. a presence of an abnormal experi-
ence such as depressed mood, hallucinations, pain, disinhibited behaviour, etc.
The phenomena of insight determined by ‘objects’ of insight with respect to this

distinction will be shaped in different ways. Thus, the phenomenon of insight that
issues in relation to a negative ‘object’, i.e. in relation to an absence of a normal
function or experience, will necessarily be focused on awareness (in the narrow
sense) of this loss. Where loss of function is concerned, this will determine a phe-
nomenon of insight that has to be primarily concentrated on awareness or know-
ledge of that loss. Such a phenomenon will, therefore, be constituted of judgements
which are limited in numbers and scope, and which give rise to a phenomenon that
is correspondingly narrow and fairly sharply encapsulated in structure. Even when
there is some awareness of the particular deficit on the part of the patient, further
judgements concerning this knowledge will be limited to possible assessments
of severity of the deficit and, rarely, impact of the deficit on functioning. For exam-
ple, in patients with dementia, where memory problems are taken as the ‘objects’ of
insight assessment, the phenomenon of insight that is elicited becomes structured
in terms of judgements mainly concerned with how severe the memory problem
is regarded by the patient (e.g. compared with some time ago, or compared to
other people, or in terms of mistakes made or frequency of problems, etc., see
Chapter 5).
In contrast, the phenomenon of insight issuing in relation to a positive ‘object’,
i.e. in relation to the presence of an abnormal experience, determines a phenom-
enon of insight that has to rely on much wider judgements. The focus here is on the
presence of something that is not normally there and, consequently, judgements
need to reflect this not only in terms of acknowledging the presence of this state
but also in terms of evaluating what this actually means (given that this is not the
normal state), in what way this is abnormal and how it affects the individual. For
example, a patient with schizophrenia may complain of ‘voices’ interfering with
his/her thoughts. If the ‘object’ of insight is taken as ‘auditory hallucinations’, the
phenomenon of insight that will be elicited in relation to this will incorporate not
only the awareness of hearing voices, but equally, since these may be offered as
complaints, they will also incorporate what these represent for the individual in
terms of their meaning, sense and effects. The phenomenon of insight in this situ-
ation, constituted by such judgements, has to be wider and less circumscribed than
a phenomenon of insight whose core structure is focused on an awareness of loss.
7.3.3.3 Insight–insightlessness dichotomy

Whilst this dichotomy does not distinguish between the natures or kinds of
‘objects’ of insight assessment, it does distinguish between perspectives from which
the ‘objects’ are viewed. It is relevant to consider this here because, in conjunction
with the other dichotomous factors, this distinction affects the shape of the phe-
nomenon of insight that is elicited. Thus, when the ‘object’ of insight assessment is
240 Conceptual
approached from the perspective of insight, e.g. insight into mental symptoms, or
awareness of activities of daily living, or insight into behavioural changes, etc. the
phenomenon of insight that ensues will naturally include additional judgements
relating to the degree or extent of insight held. This will occur irrespective of how
narrow or wide the elicited phenomenon becomes. In other words, from the per-
spective of ‘insight’ (or ‘awareness’), the ‘object’ of insight assessment will demand
a phenomenon that, whether or not taken up in research or empirical terms, incorp-
orates judgements that involve ratings of the insight. For example, exploring
insight into mental symptoms or awareness of memory problems, etc. will deter-
mine a phenomenon of insight based on judgements which can include the extent
of knowledge individuals will have concerning their mental symptoms or their
memory problems. Again, the issue is not whether in empirical terms such know-
ledge is actually sought. The point is, however, that the phenomenon of insight
elicited in relation to this perspective has the potential in terms of its structure to
include such judgements.
On the other hand, when the ‘object’ of insight assessment is approached from
the perspective of ‘insightlessness’, for example, unawareness of mental symptoms,
or anosognosia in relation to hemiplegia or amnesia, etc., the phenomenon of
insight that ensues is generally much more limited or narrower in structure simply
because the other judgements do not follow in the same sort of way. Thus, and as
was mentioned earlier, if an individual has no insight into his/her inability to move
a leg or no insight into the fact that he/she has memory problems, then judgements
concerning degree or extent to which the individual does not know cannot develop.
If a patient does not ‘know’ that he/she is unable to walk, then he/she cannot judge
the effect of this inability. In fact, as we have seen, speaking empirically, judgements
have been incorporated into measures purporting to evaluate ‘unawareness’ or
‘anosognosia’ but in those situations, what is actually being assessed is degree of
awareness and it becomes a purely semantic point. From the theoretical perspective,
however, and borne out by the historical origins of the conceptualisations of insight
(in general psychiatry) and insightlessness (in neurosciences), respectively, the
following observation can be made. The phenomenon of insight determined by
the ‘object’ of insight assessment will be narrower and more circumscribed in
structure when approached from the perspective of insightlessness than when elicited
from the perspective of insight.
It has to be acknowledged that, the dichotomies identified here with respect to the
‘object’ of insight assessment are not operating independently but interact in terms
of their effects on the phenomenon of insight. Separating them as has been done
in this section, however, helps to demonstrate the various different ways in which
the nature of the ‘object’ of insight assessment will influence the structure of the
phenomenon of insight elicited.
7.4 Conclusion
Insight is a relational or ‘intentional’ concept, i.e. it is only understood in terms of

its relation to something. It makes little sense to talk about a person’s insight without
there being something to have insight about. This ‘something’ has been referred to
as the ‘object’ of insight assessment and, in clinical practice, includes any chosen
state relating to the individual: mental or physical, pathological or non-pathological.
It has been argued that the ‘object’ of insight assessment has a crucial role in deter-
mining and shaping the clinical phenomenon of insight. In contrast to the previous
chapter where the clinical phenomenon of insight was explored in terms of some
of the definitional problems around the conceptualisation of insight itself and the
interpretational issues inherent to the elicitation of the phenomenon, here the
clinical phenomenon of insight is explored in the context of its relational aspects,
namely from the perspective of its ‘object’.
Three separate ways in which the ‘object’ of insight assessment can shape the
clinical phenomenon of insight have been identified. Firstly, the ‘object’ of insight
assessment is itself embedded within the conceptual framework guiding or under-
lying a particular professional discipline. This same conceptual framework will
impose a similar structure (in terms of rules, concepts, assumptions, language,
etc.) on the phenomenon of insight elicited within that discipline. Secondly, the
semantic category to which the ‘object’ of insight assessment belongs (i.e. the type
of term to which the ‘object’ refers) will exert its specific structure on the phenom-
enon of insight. This is particularly apparent when considering the difference in
order of meaning between ‘objects’ referring to a wide multifactorial construct
such as ‘mental illness’ and those referring to a narrower ‘objectively’ determined
concept such as ‘neurological’ or ‘neuropsychological impairment’. Thirdly, the
specific nature of the ‘object’ of insight assessment itself will determine to some
extent the sort of insight phenomenon that will be elicited. In this context, it is
shown that various dichotomous factors can play a part in the shaping of the
insight phenomenon. Among those, of particular importance is the subjective–
objective dichotomy, i.e. whether the nature of the ‘object’ of insight assessment
refers to a subjective state as opposed to a so-called ‘objective’ state. Where, in fact,
the ‘object’ of insight assessment refers to subjective states (e.g. depressed mood,
hearing voices, feeling persecuted, etc.), the core structure of the phenomenon of
insight elicited must, by definition, share the structural components of the ‘object’,
i.e. the subjective state, itself. In other words, in the articulation of subjective com-
plaints, individuals are making judgements of their experiences based on awareness
of those experiences. Consequently, a core aspect of the phenomenon of insight
will be inherent to the subjective complaints themselves. This necessitates the phe-
nomenon of insight in relation to such states to form a broader structure, one which
242 Conceptual
includes wider judgements concerning the nature, meaning and effects of such
experiences on the self.
The relational aspects of insight carry important implications for understand-
ing and research on insight. Most importantly, since clinical phenomena of insight
are determined to some extent by the ‘object’ of insight assessment, then phenom-
ena of insight in relation to different ‘objects’ of insight assessment will vary in
structure and, consequently, will likely involve different underlying mechanisms.
This means that assumptions held concerning equivalence between insight phe-
nomena in relation to different clinical studies will need to be qualified. Similarly,
results of different studies will need to be interpreted in the context of the particu-
lar insight phenomenon under investigation.
8
Towards a structure of insight: awareness

and insight, an essential distinction?
Various conceptual issues arising in the study of insight have now been identified
and their likely role explored with respect to providing some explanation for the
variable results obtained in empirical work on insight. It is evident that empirical
research on insight faces many difficulties most of which relate to the ways insight
is treated theoretically and to the sense that is made of the clinical phenomenon
elicited. These, in turn, reflect the complexities inherent to the nature of insight as
a concept. It remains crucial, however, notwithstanding the difficulties involved, to
continue with efforts focused on clarifying and understanding the conceptual
problems surrounding the study of insight. The meaningfulness of empirical stud-
ies, i.e. their theoretical significance and clinical importance as well as their limita-
tions, is necessarily dependent on the level of such conceptual understanding.
While the previous chapters focused on unpacking some of these conceptual prob-
lems, these last two chapters aim to bring together the identified points and issues
with a view to developing a basic preliminary structure for the concept of insight.
This chapter focuses on exploring the distinction between awareness and insight,
and determines this as theoretically important and clinically relevant. The next
chapter explores the relationship between awareness and insight in the context of
a proposed overall structure for insight.
In Chapter 1, and following Berrios (1994a; 1996), it was pointed out that terms,
concepts and behaviours do not inevitably correspond in a one-to-one manner to
an object of inquiry. Thus, in order to understand the historical origins and devel-
opment of the object in question, it is necessary to deal with the histories of the
terms, concepts and behaviours independently, before points of convergence can be
considered. This method was followed in the historical Chapter. It is of interest, how-
ever, how the subsequent reviews of empirical studies on insight in different clin-
ical conditions bring this lack of correspondence to a particularly overt focus,
although clearly from a different, i.e. non-historical perspective. This is evidenced
mainly through the use of a range of related terms to variably defined concepts. As
was shown in the previous chapters, the same term could be used to refer to differ-
ent sorts of concepts (e.g. ‘lack of insight’ could refer to both a lack of perception
of a deficit/problem as well as to a lack of an understanding of the nature and
243
244 Conceptual
consequences of the problem). Equally, different terms could be used to refer to

a similar sort of concept (e.g. ‘unawareness’, ‘poor insight’, ‘anosognosia’, ‘denial’,
‘impaired self-awareness’, etc. used interchangeably to refer to one particular concept
of lack of recognition of problems). The interchangeable use of related terms osten-
sibly referring to one concept is particularly apparent in studies exploring insight in
organic brain syndromes (e.g. Verhey et al., 1993; Chapter 5). Occasionally, in such
studies, conceptual distinctions are made between the uses of the different terms
(e.g. Reed et al., 1993; Weinstein et al., 1994; Vasterling et al., 1995) but in the main
such distinctions are infrequent and, moreover, tend to be inconsistent in regards to
the content of the ensuing conceptual categories. For example, Reed et al. (1993) use
the terms ‘anosognosia’ and ‘unawareness of memory impairment’ interchangeably
but distinguish these from ‘denial’ which they view as referring to a different concept,
one incorporating affective changes. On the other hand, Weinstein et al. (1994) use
the terms ‘anosognosia’ and ‘denial’ interchangeably but distinguish these terms from
‘loss of insight’ which they conceive as a different concept.
However, despite this source of confusion from the terminology and conceptual
referents, I would argue that one distinction has emerged particularly, clearly and con-
sistently in both the empirical research reviewed and in the conceptual analyses
carried out. This is the general conceptual distinction between insight as a concept in
the narrow sense (i.e. solely concentrated on awareness or perception of a problem,
henceforth termed ‘awareness’) and insight as a concept in a wide or broad sense (i.e.
involving other sorts of judgements in addition to the awareness of a problem, hence-
forth termed ‘insight’). The important question, however, lies in whether this distinc-
tion in concepts is a valid distinction, in the sense of being meaningful from the
perspective of understanding the structure of insight and in terms of its usefulness for
the further exploration of insight empirically. This chapter, therefore, is concerned
with addressing this question by firstly, clarifying the theoretical grounds for the dis-
tinction and secondly, by providing some empirical justification for the distinction.
8.1 Theoretical grounds for distinguishing between awareness and insight
As mentioned above, setting aside the variable terminology, the literature and
research that was examined in the earlier chapters provide grounds for making a
conceptual division between ‘awareness’ and ‘insight’ as a narrow and wide concep-
tualisation of insight, respectively. In other words, despite the interchangeable use of
terms (including awareness, insight, etc.), two distinct concepts relating to insight
can be identified as running in parallel, albeit, also converging and interacting. The
distinguishing point between these concepts, I will argue, revolves around the nar-
rowness or breadth of the concept involved and, as already stated, the terms ‘aware-
ness’ and ‘insight’ will be used, respectively, from now on, to refer to these specific
245 Awareness and insight: an essential distinction?
senses. The immediate question that arises with respect to this claim, must be what
are the grounds for making this particular distinction? After all, we have seen
throughout the book that in fact, there appear to be numerous distinctions between
the various ways in which insight is conceived and, indeed, this fact has been con-
tinuously discussed and emphasised. However, the point I want to make here is that,
whilst there are many different distinctions proffered in the conceptualisation of
insight, the distinction between ‘awareness’ and ‘insight’ is of unique importance
firstly, because this has direct implications for the structure of insight and, secondly,
because this is essential for understanding the clinical phenomena elicited in rela-
tion to these concepts. In order to substantiate this claim we first need to under-
stand what specifically is meant by a narrow and a wide concept of insight in the
context of the sorts of conceptual distinctions that can be identified. Therefore, it is
important to revisit some of the distinctions that have been made in the literature
between concepts of insight in order to then identify and focus on the features that
differentiate the nature of this particular distinction, i.e. on the ‘narrow’ (as ‘aware-
ness’) and ‘wide’ (as ‘insight’) concept, from other types of distinctions.
Chapter 1 referred to some of the distinctions formulated by the earlier alienists.
For example, amongst patients who seemed to show some insight into their condi-
tion, i.e. those who were aware of the pathological nature of their experiences,
Billod (1870) distinguished between those who, despite this awareness, judged
their psychotic symptoms as ‘real’ and those who judged their psychotic symptoms
as ‘false’, albeit still experiencing distress as a result. Parant (1888) made several
additional distinctions between different forms of insight that patients could show.
These were based on other types of judgements, e.g. judgements concerning the
morality of their actions, judgements that their experiences were pathological, dis-
crepancies between patients’ judgements, their behaviours and so on. Pick (1882),
using the term ‘awareness of illness’ (Krankheitsbewußtsein) conceived a broad
concept of understanding that patients had concerning the pathological nature
of their experiences and divided this further into ‘awareness of feeling ill’
(Krankheitsgefühl) and ‘insight into illness’ (Krankheitseinsicht). In other words, his
distinction was based on changes in feeling in the case of the former and processes
of reason or reflection in the case of the latter. On the other hand, Arndt (1905)
argued for this same distinction (i.e. between awareness of feeling ill and insight
into illness) to be based on the degree of clarity with which the feeling/knowledge
was experienced. Influenced to some extent by Pick, Jaspers (1948) made a distinc-
tion between ‘awareness of illness’ (Krankheitsbewußtsein) and ‘insight proper’
(Krankheitseinsicht). He conceived the former concept as referring to experiences
of feeling ill and changed but without this capturing all symptoms or the illness as
a whole. The latter, on the other hand, referred to a concept which encompassed a
correct assessment made by the patient of the nature and severity of all symptoms
246 Conceptual
together with the illness as a whole affecting him/her. Therefore, it can be seen that
various types of distinctions between concepts of insight were made. Divisions
have been drawn, e.g. between thoughts and feelings (Jaspers, 1948; Pick, 1882),
between thoughts and behaviours (Parant, 1888), between degrees of clarity/detail
in knowledge (Arndt, 1905; Aschaffenburg, 1915) and between specific types of
thoughts/judgements (Billod, 1870; Parant, 1888), etc.
If we move on to the clinical areas of general psychiatry and psychoanalytic psych-
ology, we find that again various distinctions between the concepts of insight have
been made. In general psychiatry, it was pointed out that views of insight ranged
from the more narrow, such as recognition of illness (Wing et al., 1974; Heinrichs
et al., 1985), to much wider concepts which included further judgements demanded
in relation to a variety of aspects of the patient’s experiences (Greenfeld et al., 1989;
David, 1990; Amador et al., 1991; Marková & Berrios, 1992a). The distinctions con-
tained within these various conceptions of insight thus lie around the numbers and
types of judgements involved concerning the patients’ experiences. In some cases the
judgement or acknowledgement of being ‘ill’ was sufficient in itself to constitute
insight and in other cases, additional elaborations concerning views about the nature
of illness or symptoms, the social consequences of the illness, need for treatment, etc.
were necessary to determine insight (Chapter 3). In psychoanalytic psychology, we
have seen that insight has been conceived even more broadly so that the judgements
demanded of individuals in the elicitation of the phenomenon have been more com-
plex. Here, distinctions between such judgements have been made not only with
respect to the different types of judgements, i.e. extent of understanding patients have
of different aspects of their experiences, but also of the ways in which such judge-
ments might be assimilated. Thus, distinctions are made according to whether
knowledge is attained in a relatively more superficial sense (e.g. intellectual, cognitive
or descriptive insight) or whether it is in a relatively deeper sense (e.g. ostensive or
emotional insight, etc.) and according to the extent to which judgements relate to
more ‘hidden’ knowledge including unconscious processes underlying motivations
and actions (Reid & Finesinger, 1952; Richfield, 1954; Chapter 2).
In neurological states (Chapters 4 and 5), we saw that there was a much more
explicitly described polarity between awareness (or unawareness) of neurological
impairment in the narrow sense and denial of impairment in the wider sense. The
former referred to insight as the perception or awareness of the specific impair-
ment and the resultant phenomenon of awareness was thus simply based on
judgements acknowledging the presence of the impairment. On the face of it, this
particular conception of insight is striking in its immediate contrast to the views of
insight seen in the psychiatric literature where even the relatively narrow concep-
tions of insight lacked the clearly-defined and circumscribed boundaries of the
‘neurological’ concept. As was demonstrated, instruments for assessing the clinical
phenomenon of awareness or unawareness have become increasingly sophisticated

in terms of their attempts at characterising awareness. However, this core concept
has remained focused on the narrow sense of awareness and subsequent distinc-
tions have revolved around judgements concerning the specific features of the
impairment (i.e. severity, frequency of problems caused, etc.). Denial, on the other
hand, referred to a concept in which awareness of the impairment was viewed as
implicit, or present at some level. Nevertheless, this was prevented from becoming
overtly manifest through the patient’s psychological processes acting to ‘protect’
the patient from the distress engendered by the knowledge (Weinstein & Kahn,
1955). Thus, this broader concept includes within its definition a postulated reason
for the manifested phenomenon.
Therefore, it is apparent that various types of distinctions have been made in
studies of insight in the different clinical areas and disciplines. It can be argued that
they all range in different ways from ‘narrow’ to ‘wide’ concepts. However, amongst
the various distinctions, there does seem to be a more prominent and consistent
difference between views of insight in the narrow sense as in the neurosciences and
the views of insight in the broader sense as in general psychiatry and psychoana-
lytic psychology. Whether some of the additional distinctions proposed within this
latter broad concept of insight (such as the distinctions mentioned above made by
the earlier alienists and those seen in the studies within general psychiatry and
psychoanalytic psychology) are theoretically important and/or clinically useful
remains to be answered and may form empirical questions of the future. However,
the important issue here is that those latter distinctions are still bound within a
broad concept of insight and there is not the clear separation of concepts that there
seems to be when awareness as the narrow concept and insight as the broad concept
are contrasted. This is evident not only in the explicit definitions used in the
neurosciences and psychiatric clinical areas but also in the ways in which the
respective phenomena of insight are elicited/manifested and evaluated.
Before focusing more specifically on the difference between awareness and
insight, further grounds for this distinction are also evident from the exploration
of the relationship between the phenomenon of insight and its relational ‘object’
(Chapter 7). Disciplinary backgrounds were found to be important in this respect
and it was shown how ‘objects’ of insight assessment embedded in different theor-
etical backgrounds could determine phenomena of insight that differed in their
narrowness or breadth. However, more significant was the influence of the kind or
nature of the ‘object’ of insight assessment itself in shaping the phenomenon of
insight elicited. Here, it became particularly apparent how, according to their
nature, ‘objects’ could determine the narrowness or breadth of the phenomenon of
insight. In this regard, the features of ‘objects’ of insight which were found to deter-
mine a broader phenomenon of insight, in terms of the complexity of judgements
248 Conceptual
demanded and their relationship to the self, were those relating to subjectivity
(where insight is explored into an experience that by definition incorporates some
awareness), positivity (where insight is explored into the presence of an abnormal
experience) and where the ‘object’ of insight was explored from the perspective of
insight as opposed to insightlessness. Furthermore, where ‘objects’ of insight
assessment referred to a more complex construct (such as ‘mental disorder’), the
phenomenon of insight determined by this ‘object’ was correspondingly broader in
terms of its contained judgements. It is of important note that all these features
relating to the ‘objects’ of insight assessment are those most characteristic of
‘objects’ as defined mainly in psychiatric disciplines. In the neurosciences, on the
other hand, the ‘objects’ of insight assessment are more likely to be objective in
nature (referring to the issue of being determined specifically by tests or a clin-
ician), negative in type (referring to the absence or impairment of normal function)
and approached from the perspective of insightlessness. In turn, such ‘objects’ as
was demonstrated earlier, determine a phenomenon of insight that has to be much
narrower and circumscribed in structure.
8.1.1 Nature of the boundary between awareness and insight

Therefore, so far we have seen from the literature that the broad distinction between
awareness and insight is suggested by the way in which insight has been conceptu-
alised and clinically evaluated within the different clinical disciplines. We have seen
how the neurosciences have tended to favour the narrower conception of awareness,
driven by their particular theoretical framework together with the nature of the
‘object’ of insight assessment encountered by their disciplines. Likewise, the psychi-
atric disciplines have tended to favour the wider conception of insight, driven in turn
by their particular theoretical framework together with the specific types of ‘object’
of insight assessment met with in general psychiatry. Therefore, the next question
concerns the nature of the specific distinction between awareness and insight that is
being claimed above. How can narrowness and width be defined in this sense? In
other words, where is the line that, it is argued, demarcates the narrow concept of
awareness from the wider concept of insight? When exactly do judgements become
of the sort and complexity that would indicate insight rather than awareness?
As already emphasised, this crucial distinction seems to emerge most clearly
from the comparison of conceptions of insight between the neurological/neuro-
psychological clinical areas on the one hand and the psychiatric/psychoanalytic
psychological clinical areas on the other. Determined, as was shown in the previous
chapter, by the nature of the ‘object’ of insight as a neurological or neuropsycho-
logical deficit or loss of function, the conception of insight in the neurosciences
has focused on awareness in its most narrow sense, i.e. perception of, or know-
ledge at its simplest level in relation to, a particular stimulus (or in this case loss of
stimulus). However, we have seen that ‘narrow’ conceptions of insight have also
been found in the work of the earlier alienists as well as in the empirical research
reviewed in general psychiatry. Therefore, why is the line being drawn between
awareness as construed in the neurosciences and awareness or insight as presented
in the various psychiatric clinical areas?
The answer appears to lie once again in the crucial difference between the ‘objects’
of insight assessment in these respective areas. Even when the most narrow views
of insight within psychiatry are examined (narrow in the sense of being presented
as unitary definitions with no further explication), e.g.‘awareness of emotional prob-
lems’ or ‘recognition of mental illness’, the phenomenon of insight/awareness
demanded by the ‘objects’ in these cases, i.e. ‘emotional problems’ or ‘mental ill-
ness’, will always be wider than the phenomenon of insight/awareness determined
by the ‘objects’ focused on in the neurosciences (i.e. neurological deficits or neuro-
psychological impairments). In other words, and for reasons that were explored in
the previous chapter, whether termed ‘awareness’ or ‘insight’, the phenomenon
sought and elicited within psychiatry (and psychoanalytic psychology) will be con-
stituted of judgements which reach beyond that of an awareness or perception of
‘impairment’. In a sense, awareness or perception of change must, to some extent,
be a given in the conceptualisation of insight within psychiatry (with some qualifi-
cations, see later) but it is, in effect, the subsequent judgements based on this
awareness that constitute insight. This is the case because, again as was demon-
strated in the previous chapter, insight or awareness of, e.g. ‘mental symptoms’, in
reality refers to more than the awareness of the presence of the symptoms (in an
akin manner to the presence of a neurological impairment). In addition, it refers to
awareness of the sense the mental symptoms make to the patient, i.e. of the judge-
ments he/she makes concerning the nature and/or morbidity of the experiences.
Likewise, insight or awareness of having a ‘mental illness’ refers to the judgements
the patient makes in the context of awareness of a variety of subjective experiences.
It is thus these judgements that are determined by the ‘objects’ of insight in psychiatry
that constitute the difference between awareness and insight. In turn, it is the nature
of the differences in ‘objects’ (with respect to the relevant discipline, the category
type and the relative position along the dichotomous dimensions identified earlier,
Chapter 7), determining the presence of such judgements, that fixes this distinction
between awareness and insight. Distinctions between various concepts of insight
identified by the early alienists or those identified in the empirical exploration of
insight in general psychiatry are based on the types of subsequent judgements
made on, already assumed, awareness of experiences. On the other hand, the dis-
tinction between the concept of insight in the neurosciences and the concept of
insight in psychiatry is based on the focus on awareness in the former and focus
on judgements based on awareness in the latter. Awareness may be a necessary
250 Conceptual
component of insight but it is not a sufficient component in the conceptualisation

of insight as explored in psychiatry.
Having provided some grounds for making the specific distinction between
awareness and insight both in terms of reviewing the sorts of conceptual distinc-
tions that have been made within different clinical areas and by arguing for the
crucial role that the ‘object’ of insight assessment has in determining the narrow-
ness and width of the phenomenon elicited, the question remains as to where, in
practical terms, this boundary between awareness and insight lies. One way to
address this question is to compare the clinical phenomena that are elicited in rela-
tion to each of these concepts, i.e. in relation to awareness and insight and thus
examine in clinical terms the sorts of features representative of both.
8.1.2 Awareness and insight: similarities and differences
8.1.2.1 Phenomenon of awareness

Taking first the phenomenon of awareness as elicited or manifested in relation to
neurological deficits or impairments, we have stressed that the phenomenon is
based on a narrow conception of awareness as a simple perception of the
deficit/impairment. Thus, measures to assess this awareness have focused on,
firstly, determining whether awareness of the impairment is present or absent and,
secondly, provided that awareness is present, then on characterising this in terms of
the specific impairment (or ‘object’) itself. In other words, degrees of awareness are
evaluated with respect to the perception or judgement on the part of the patient of
the severity of their problem, or the frequency with which the problem interferes
with something, or how it compares with ‘before’ or with ‘healthy’ people, etc. This
gives a quantitative measure of awareness (a patient is said to have no awareness,
full awareness or a measure/score in between) but, at the same time and somewhat
confusingly, gives an impression of a qualitative assessment. However, this impres-
sion of a qualitative assessment comes from the fact, that it is the qualitative aspects
of the impairment itself that are being sought by the awareness measure rather
than the qualitative aspects of awareness. In other words, it is not the nature of the
awareness in relation to the ‘object’ (impairment) that the patient is being asked
about, but, the awareness in relation to the nature of the ‘object’ (impairment). Thus,
in a sense, so-called qualitative aspects of awareness are elicited only on the basis of
qualitative aspects of the impairment, i.e. the ‘object’ itself, as far as these can be
gauged by the external individual (e.g. types of memory problems experienced as
assessed by a range of psychometric tests, types of activities of daily living the
patient is unable to carry out independently, etc.). Awareness, per se, is therefore
evaluated principally quantitatively. In fact, this makes sense given the nature of
the ‘object’ of awareness assessment explored in the neurosciences, namely its
negative (i.e. loss or impairment of function) and objective qualities (i.e. directly
evident on observation or tests). Consequently, as far as awareness is concerned,
the focus has to be on the patient’s understanding of the impairment in terms of
the actual observable effects. And, because these observable effects can only be
assessed by means of quantitative measures (frequency of problems experienced,
degree of severity of problem, etc.), then awareness as a phenomenon is elicited
in a quantitative way. Qualitative aspects of awareness are simply not accessible to
the external person (clinician/carer). Hence, no comparisons between patient and
another individual can be made for the purpose of determining the patients’
‘knowledge’ or perception of what is happening to them. The only qualitative fea-
tures that are accessible for the purpose of such comparison are those features that
characterise the impairment itself. As already emphasised previously, the intrinsic
relationship between insight and the ‘object’ of insight assessment means that as
far as the phenomenon of insight or awareness is concerned, the focus of qualita-
tive features will lie on the ‘object’ of awareness in this case rather than on the
‘awareness’ itself. This is not to say that qualitative features of awareness are never
elicited within the neurosciences disciplines. There are many different areas of
clinical experiences where qualitative aspects of awareness are sought specifically,
as in delineating abnormal sensory experiences e.g. phantom limb, or even in char-
acterising various pains. However, the issue in these situations is different. The
qualitative changes in awareness that are explored in these contexts are not carried
out from the perspective of examining the understanding the patient has about a
particular experience but from the perspective of describing and presenting the
particular symptom concerned.
8.1.2.2 Phenomenon of insight

Looking in turn at the phenomenon of insight as elicited or manifested in relation
to mental illness or mental symptoms, we have stressed that the phenomenon is
based on a wider conceptualisation of insight in that it is constituted of a complex
of both awareness of change and, significantly, on further judgements concerning
the perceived nature and/or morbidity of the change. As argued previously, it is the
nature of these further judgements that makes the concept of insight in this sense
much wider. Even when termed ‘awareness of mental illness’ or ‘awareness of mental
symptom’, the concept referred to is necessarily more than ‘awareness’ simply
because of the types of judgements determined by the ‘objects’ of insight contained
in each term. This is reflected in the phenomenon of insight elicited/manifested.
For example, the sorts of judgements that might be involved in making the decision
relating to having a ‘mental illness’ will have to reach out to diverse aspects of know-
ledge and experience. This will include the individual’s own views on the definition of
‘mental illness’, which, in turn, is likely to be based, amongst other things, on several
252 Conceptual
kinds of knowledge. Among these, is the general knowledge (e.g. information from
books, media, peers, etc.), and the personal knowledge held by the individual (e.g. past
experiences in relation to self/others, the degree to which subjective experience is
thought to match the theoretical knowledge/past experiences, etc.), as well as the way
such knowledge is shaped and affected by the individual’s own attitudes (i.e. in terms
of general views of the world, personal biases, cultural perspectives, etc.). Similarly, the
sorts of judgements that might be involved in making the decision concerning the
morbidity of the ‘mental symptom’ will also have to draw on a wide range of mental
activities. These will include a personal/individual interpretation of the subjective
experience, which, in turn, is also likely to be based on a variety of factors (e.g. inten-
sity of subjective experience, difference from ‘normal’ experience, context in which
occurring, past experience, general understanding about mental illness, etc.).
Therefore, the judgements involved in making sense of an experience (whether
this is demanded in terms of ‘mental illness’ or ‘mental symptom’) incorporate a
range of heterogeneous judgements diverse in contents and type, and complexity.
Thus, in contrast to the concept of awareness, the concept of insight, even in a
narrow sense, in relation to psychiatric states, has an inherent qualitative aspect,
which can be addressed in the elicitation of the clinical phenomenon. Patients are
asked to judge in a wider sense what it is that they are experiencing in terms of
what the experience means for them and how this might affect them in their ability
to function and/or relate to others and possible implications for them (e.g. need for
treatment) (Chapter 3). These judgements relate not just to the ‘objective’ charac-
teristics of the problem or experience but to the personal sense the individuals
make of these characteristics and, more directly, to the sense in which the experi-
ence is related to themselves. Consequently, such judgements are by their very
nature qualitative in type, drawing on a wide range of experiences and knowledge
held by the individual and related to the self. Here, in contrast to awareness, it is the
nature of insight in relation to the ‘object’ (mental illness/mental symptoms) that is
being demanded of patients rather than insight in relation to the nature of the ‘object’
(mental illness). Insight, as a phenomenon, is thus assessed both quantitatively
(patients can be said to have no insight, full insight or again a measure/score in
between) and qualitatively (patients can be evaluated on the sorts of judgements
they are expressing). This makes sense given the nature of the ‘object’ of insight
assessment concerned, namely, its positive (presence of an abnormal/different
experience) and its subjective (not accessible in a direct way by the external person)
qualities. Hence, as far as insight is concerned, the focus has to be on the patient’s
understanding of the abnormal experience in terms of what sense the patient
makes of his/her symptoms, how this links up with his/her knowledge and views,
etc. These sorts of judgements are assessed by means of both quantitative (degree
to which patient acknowledges problem) and qualitative (types of judgements
expressed, e.g. acknowledgement of impact on different aspect of life, views on

need for different treatments, views on cause of problems or experiences, etc.)
measures. Qualitative aspects of insight are therefore inherent to the contents of
judgements demanded. Thus, in contrast to the phenomenon of awareness in rela-
tion to impairments, the phenomenon of insight intrinsically linked to its ‘object’
of insight assessment will have its focus on qualitative features directed at the phe-
nomenon itself rather than at the ‘object’ of insight.
8.1.2.3 Distinctions between awareness and insight

To illustrate the above described difference between ‘awareness’ and ‘insight’, it may
be useful to look at specific instances. For example, the phenomenon of awareness
into memory problems may be elicited by asking the individual to judge certain
aspects of their memory, e.g. how frequently they experience memory difficulties
or how severe these are considered to be, how they compare to memory of other
people, etc. It is clear that generally such judgements tend to relate predominantly
to features of memory function itself. The extent of the patient’s awareness is based
on the comparison between the patient’s judgements and the clinician’s/other’s
judgements of these memory function features. The phenomenon of insight into
psychosis, on the other hand, may be elicited by asking the patient to judge his/her
psychotic experiences. For example, the patient might be asked to decide what they
represent, to determine whether they are abnormal or pathological, to think about
whether they are related to a possible illness, to give a view whether treatment is
needed, to give an opinion whether and/or in what way they affect functioning or
have any impact on his/her life, etc. Such judgements, in contrast to the phenom-
enon of awareness into memory problems, relate less to ‘objective’ features of the
abnormal experiences and more to a wider assimilation and interpretation of
problems by the individual in relation to him/herself.
Bringing together some of the identified features helping to characterise and to
distinguish between awareness and insight as distinct phenomena, it is evident that
both reflect concepts which refer to some knowledge or understanding individuals
have about themselves or about particular problems affecting them. Both have at
some point been defined as not all-or-none concepts/phenomena and hence, could be
described in quantitative terms. Individuals can have more or less insight and more
or less awareness. We have seen that the concept of awareness, as used in the neuro-
sciences, has referred predominantly to a perception or acknowledgement of some
change happening to the self (i.e. loss of or impairment in some function or absence
of a normal experience) as experienced by the individual. Judgements in this sense are
simple in type because they refer to a direct appraisal of a specific impairment and can
range from recognition of change (understanding there is a change and perhaps
identifying the nature of the change, i.e. giving it a name) to evaluation of the
254 Conceptual
severity/intensity of the change. Awareness is evaluated quantitatively. The qualitative

aspects arising from awareness measures refer to the qualitative features imposed by
the impairment itself. If the structure of the phenomenon of awareness is viewed as
comprising of both the phenomenon of awareness together with its ‘object’ of aware-
ness assessment in the bi-directional relationship as described earlier, then the focus
of the qualitative aspects of awareness can be conceived as directed at the ‘object’.
On the other hand, the concept of insight as used in general psychiatry has
referred predominantly to a much wider concept of knowledge admitted by an indi-
vidual. Judgements are complex in type because they refer to an indirect appraisal
of a change to the self and depend on a range of subsidiary judgements relating to
an individual’s general knowledge, views, perceptions, past experiences, etc. Such
judgements also range from recognition of change (understanding there is a change
and perhaps identifying the nature of the change, i.e. giving it a name) to evaluation
of the severity/intensity of the change, thus allowing for a quantitative assessment.
However, in addition judgements are of a range and nature that enable a qualitative
assessment. Here, the qualitative aspects of insight arising in relation to insight
measures refer to the qualitative features imposed by the judgements themselves
both in terms of the types of contents but also in terms of their self-directedness.
Again, if the structure of the phenomenon of insight is viewed as comprising of
both the phenomenon of insight together with its ‘object’ of insight assessment in
the bi-directional relationship, then the focus of the qualitative aspects of insight in
this case can be conceived as directed at the phenomenon rather than the ‘object’.
Are there any other differences that can be identified between awareness as a
narrow concept and insight as a wider concept? In fact, another interesting factor
is raised when making a comparison between impaired awareness in patients and
impaired insight in patients and that is one of directionality. This issue will be
highlighted more clearly in the next section when an empirical study illustrating
this will be examined. Here, however, in brief, one can consider the situation where
a patient may complain of pain, which, to the external person or clinician, may appear
to be out of proportion to the likely actual pain (as far as this can be evaluated).
Alternatively, another situation might be one where patients are worried about
some sort of minor deformity (e.g. blemish or scar on their face) to the extent that
their beliefs and behaviours are adversely affected (e.g. they stop socialising with
friends, use uncomfortable masking devices, believe they are ugly, etc.). In both
these situations, one could argue that they seem to show reduced insight into their
problems (i.e. it could be said that their judgements concerning the nature and
effects of the ‘objects’ seem to be somewhat distorted or out of proportion to what
is ‘objectively’ ascertainable). On the other hand, it could equally be argued that
they seem to show increased awareness or apparent awareness of their problems
(i.e. they are judging the ‘object’ of awareness to be of particularly high intensity).
In fact, because ultimately the patient’s views are compared with those of the clin-
ician, in these situations the problems would be formulated in terms of the patient’s
insight rather than the patient’s awareness (even if termed interchangeably). This
shows very obviously that reduced insight is not the same as reduced awareness.
The issue of directionality would seem to be of some importance in also distin-
guishing between the concepts of awareness and insight. Thus, awareness is generally
conceived in terms of a reduction or absence of awareness in relation to a particular
‘object’ (e.g. in relation to memory impairment, to hemiplegia, etc.). When awareness
is conceived or discussed in terms of an increase in awareness, this tends to be a relative
increase from a level of poor awareness, rather than an increase from a ‘normal’ level
of awareness (e.g. patients showing increased awareness of their difficulties/limitations
following rehabilitation, etc.). Other situations when increased awareness may be
conceived include the sorts of clinical experiences where qualitative aspects of aware-
ness are also explored, e.g. some of the brain stimulation studies or various forms of
epilepsy, but again here the focus is not on the understanding a patient is showing in
relation to his/her experiences but on the nature of the experience itself.
Insight, on the other hand, tends to be more easily conceived as increasing as
well as decreasing with respect to a ‘normal’ level. This difference between the two
concepts is likely to be due to a number of factors. Firstly, the clinical backgrounds
relating to these concepts are important. Awareness, in the neurosciences has tended
to be modelled along neurological and neuropsychological frames in which ‘aware-
ness systems’ (generalised or inherent to specific cognitive functions) are seen as
structures or functions which can ‘go wrong’ in the same sort of way that other
cognitive functions do. Thus, whilst it is conceivable that an awareness structure or
function can become damaged by some brain lesion or disease, it is much more
difficult to think of the same structure or function becoming enhanced in some
way (without invoking the use of some specific stimulatory techniques akin to
those used to enhance other aspects of cognitive function). The clinical background
of insight in its broad conceptualisation is, as we have seen, very different and, in
various ways, the psychiatric disciplines, psychoanalytic psychology and indeed
Gestalt psychology all contribute to determining the potential for the concept of
insight to increase as well as decrease from a ‘normal’ level. From the perspective of the
psychiatric and psychoanalytic psychologies, this seems to relate to the issue of the
complexity and of the judgements involved in constituting insight and the fact
that, as was discussed earlier (Chapter 6), there is no clearly defined boundary to
the different types and qualities of knowledge that can be held in relation to differ-
ent ‘objects’. Thus, there is always the possibility or potential for increasing insight,
even from a ‘normal’ level. In the case of Gestalt psychology, we saw that insight
was conceived very much in terms of newly acquired knowledge, and hence,
involved an increase in capacity to solve particular problems.
256 Conceptual
Secondly, once again, the ‘object’ of insight/awareness assessment is also import-

ant in contributing to this difference in directionality. In the case of the neuro-
sciences, the ‘object’ of awareness assessment is generally a loss or impairment of a
normal function. ‘Normal’ or full awareness is simply linked to the presence of the
function. Generally, there is not a case for exploring awareness into normal neuro-
logical or neuropsychological function and, in a sense, it is taken for granted that an
individual can be aware of normal neurological or neuropsychological processes.
Thus, an individual walks, talks and recalls things and, if asked at the relevant points,
will be able to say that he is aware of walking, of talking and of recalling things,
though will not necessarily be occupied with this awareness during such activities.
As was seen earlier, researchers have sought to determine degrees of awareness in
healthy subjects with respect to more complex neuropsychological functions, such as
different types of memory capacities. This has been done mainly to establish the
validity of tests designed to evaluate the awareness of patients with impairment in
such functions (e.g. prediction of performance on specific memory tests, McGlynn &
Kaszniak, 1991a, b). However, when the function becomes impaired or lost, then
awareness of this impairment or loss can either be preserved or be likewise impaired
but it makes little sense to conceive of awareness as increasing from a ‘normal’ level.
In the case of general psychiatry, the ‘object’ of insight assessment generally refers
to the presence or appearance of an abnormal experience. Here the situation is dif-
ferent because the individual is being asked to make judgements about his/her new
or additional experience rather than about a loss or impairment of a normal func-
tion. It is not the question of a ‘normal’ insight held into the new experience simply
because it is a new experience. In other words, an abnormal experience is not linked
to normal insight in the same way as a normal function is linked to normal aware-
ness. Patients making sense of their new experiences can be conceived as developing
more or less insight. Indeed, ultimately it is potentially possible that patients attain
a greater level of insight than they held in their pre-morbid state because of the
types of judgements they may be invoking (e.g. exploring their ideas and views
about themselves as well as their experiences). In a similar sort of way, individuals
embarking on psychoanalytic psychological treatment where the ‘object’ of insight
assessment may relate not just to abnormal experiences but to behaviours and pat-
terns of thinking, it is possible to conceive insight as increasing with respect to the
types of judgements that individuals are exploring in themselves.
8.2 Empirical justification for distinguishing between awareness and insight
Having explored some of the theoretical reasons for making a distinction between
awareness as a narrow concept and insight as a broad concept, let us consider an
empirical study that may help illustrate some of the issues raised. The study is
described in detail elsewhere (Marková et al., 2004) and here only the salient
aspects are presented and discussed. Essentially, the study was designed to explore
insight into memory problems in a heterogeneous group of patients attending
a memory clinic, i.e. in patients presenting with memory problems of various
aetiologies. Crucially, such aetiologies spanned both ‘organic’ (e.g. neurological,
mainly dementia) and ‘non-organic’ (e.g. depression, anxiety and others) factors.
Hence, this study contrasted from previous studies which tended to focus on the
exploration of insight in relation to either memory problems in dementias (e.g.
Verhey et al., 1993; Seltzer et al., 1995a; Duke et al., 2002; Chapter 5) or amnesic
syndromes (e.g. Schacter, 1991; 1992; Chapter 4) but did not, generally, cut across
the organic/non-organic categories.
The more specific aim of the Marková et al. (2004) study was to compare insight
between patients with an organic basis (i.e. neurological pathology) and patients
without an organic basis (i.e. no neurological pathology) to their memory prob-
lems. This perspective was taken in the light of some of the conceptual problems
around insight raised earlier. Thus, in order to circumvent some of the identified
preconceptions resulting from the conventional conceptualisations of insight in
neurological/neuropsychological and the psychiatric disciplines, patients’ insight
was explored, in a sense, independently of the cause of the memory problem. All
patients presented with memory complaints; and thus ‘memory complaints’ were
chosen as the ‘object’ of insight assessment. By using the same instrument to assess
insight across the diagnostic categories (i.e. loosely, ‘organic’ and ‘non-organic’),
and applying the same ‘object’ of insight assessment (‘memory complaints’), the
intention was to compare insight manifested between the patient groups and assess
whether the phenomena of insight shared common patterns and hence could be
‘explained’ in terms of a single concept of insight or whether different patterns
emerged and needed reference to more than one concept.
8.2.1 Methods and subjects

Insight into memory complaints was assessed by means of a simple 19-item ques-
tionnaire, the Memory Insight Questionnaire (MIQ), which asked patients to rate
their problems in various memory-related areas (general functioning, memory
itself, language and cognition). Scoring on the MIQ items was based on a 4-point
scale: 1: improvement; 2: no change; 3: mildly worse and 4: much worse. A higher
total score thus indicated a greater degree of perceived problem. In line with other
studies in this area, insight was determined as the discrepancy in ratings between
patients and carers (therefore assuming that carers gave the ‘correct’ appraisal) and
so carers were asked to rate their assessments of patients’ problems using the same
questionnaire (but referring to the patient). The level of insight was calculated as
the difference between ratings by patients and carers.
258 Conceptual
One hundred consecutive patients referred to the ‘Memory Clinic’ at

Addenbrooke’s Hospital, Cambridge, were given the MIQ as part of their overall
assessment. Patients attending the clinic were examined in turn by the neurology,
psychiatry and neuropsychology teams. Patients received a core neuropsychology
battery which included: Verbal IQ (WAIS-R), NART IQ, digit span, vocabulary,
arithmetic, similarities, block design, fragmented letters (VOSP), McKenna Naming
Test, Warrington Recognition Memory Test for words and faces, Wechsler Memory
Scale for passages and designs (immediate and delayed recall), verbal fluency, WCST
and/or the Weigl (details and references of individual tests are in Lezak (1995).
Patients and carers were interviewed separately and in addition to the psychiatric
interview, patients completed a core of computerised psychiatric questionnaires:
General Health Questionnaire 28 (Goldberg & Hillier, 1979), Cognitive Failures
Questionnaire (Broadbent et al., 1982), Beck Depression Inventory (Beck et al.,
1961), Signal Detection Memory Test (Miller & Berrios: Recognition memory by
means of a word-based signal detection analysis, unpublished, based on Miller &
Lewis, 1977), Irritability Scale (Snaith et al., 1978), Dissociation Questionnaire
(Riley, 1988) and a Personality Inventory (Bedford & Foulds, 1978). Additional ques-
tionnaires relating to specific problems were given where appropriate, e.g. Maudsley
Obsessional Compulsive Inventory (Rachman & Hodgson, 1980). Carers were asked
to complete the TRIMS behavioural problem checklist (Niederehe, 1988).
On the basis of a unified diagnosis by the three clinical teams and for the purpose
of analysis, patients were divided into those with ‘neurological’ memory dysfunction
(n 56), henceforth termed the ‘neurological’ group and those without ‘neuro-
logical’ memory dysfunction (n 44), henceforth termed the ‘psychiatric’ group. In
broad terms, the neurological group mainly included patients with Alzheimer’s dis-
ease (n 32) and a few patients with vascular dementia, traumatic brain damage,
cerebrovascular incidents and encephalitis. The psychiatric group included patients
with affective disorders classifiable under ICD-10 (World Health Organisation, 1992)
and DSM-IV (American Psychiatric Association, 1994) as either depressive and/or
anxiety disorder. Many however, could not be classified within the above systems but
nevertheless showed patterns of affective/cognitive and behavioural symptoms, and
personality traits which seemed to be related to some ongoing mental/personality
disorder. They all had distressing and disabling memory complaints.
8.2.2 Results of study
8.2.2.1 Sociodemographic and clinical comparisons

Sociodemographic data are shown in Table 8.1. The ‘neurological’ sample was
slightly older but there were no other differences in terms of sex ratio, duration of
memory problems, education, alcohol dependency or smoking.
Table 8.1 Neurological and psychiatric patients compared on socio-demographic variables
Neurological group Psychiatric group

Variable (n 56) (n 44) Statistics
Mean age (S.D.) 63.02 (12.76) 52.16 (11.64) P 0.001a

Sex (males:females) 34:22 23:21 NSb
Mean duration of memory 39.79 (35.89) 51.45 (38.18) NSa
complaints in months (S.D.) (n 56) (n 42)
Alcohol (significant:non- 3:53 (n 56) 3:40 (n 43) NSb
significant intake)
Smoking (significant:non- 11:37 (n 48) 4:36 (n 40) NSb
significant)
Education (primary:secondary: 19:26:10 (n 55) 14:20:9 (n 43) NSb
higher)
a
t-test for independent samples.
b
Chi-squared.
S.D.: Standard Deviation.
Comparison of the two samples in terms of the computerised psychiatric ques-

tionnaires is shown in Table 8.2 and of neuropsychological performance in Table 8.3.
The ‘neurological’ sample scored significantly lower on the Beck Depression
Inventory (P 0.0135) and had significantly higher scores on the Cognitive
Failures Questionnaire (P 0.0015) and on the Signal Detection Memory Test
(d scores: P 0.0015).
Unsurprisingly, the neurological patient group performed significantly worse
on a number of neuropsychological measurements, particularly on the memory
tests for recognition and recall but also on the McKenna Naming Test, fragmented
letters and similarities. The neurological patients were also significantly worse on
tests of frontal lobe dysfunction, i.e. the WCST and/or the Weigl (2 9.57,
P 0.001).
8.2.2.2 Comparison of MIQ scores between neurological and psychiatric groups
Total insight scores

For each of the 19 items on the MIQ, the patient’s score was subtracted from the
carer’s score. The 19 discrepancy values fell into three groups:
1 discrepancy 0 – indicating full agreement (i.e. good insight),

2 positive discrepancy values – indicating that the patient’s memory problem was
evaluated as more severe by the carer than the patient (i.e. poor insight),
260 Conceptual
Table 8.2 Neurological and psychiatric groups compared on main psychiatric measurements
Median value (inter-quartile range)
Neurological Psychiatric Mann– Significanceb

a
Psychiatric measure group group Whitney U 2-tailed
Beck Depression Inventory 6 (2.25–12) 10.5 (6–19) 570.0 P 0.0135

(n 44) (n 44)
Carers’ Checklist (TRIMS-BPC) 47 (26–82) 73 (24.5–122.5) 579.5 NS
(n 47) (n 29)
Cognitive Failures Questionnaire 93 (75–98) 73.5 (58–83) 422.5 P 0.0015
(n 39) (n 44)
Dissociation Questionnaire 7.5 (6–12) 10 (8–11) 329.0 NS
(n 24) (n 31)
General Health Questionnaire 28 4 (1–8.75) 8.5 (2.25–14) 766.5 NS
(n 48) (n 44)
Maudsley Obsessional Compulsive 6.5 (3.25–9.25) 7 (4–14) 67.0 NS
Inventory (n 8) (n 19)
Personality Inventory dominance 29 (27–30) 29 (26.75–31) 514.0 NS
subscale (n 31) (n 34)
Personality Inventory extrapunitive 27 (25–29) 27.5 (25–30) 479.0 NS
Personality Inventory intropunitive 32 (30–33) 30.5 (29–32.25) 394.5 NS
Signal Detection Memory – 1.31 (0.7–3.08) 3.66 (1.49–8.38) 572.5 P 0.015
value (n 44) (n 44)
Signal Detection Memory – d 1.27 (0.63–1.67) 1.9 (1.54–2.28) 436.5 P 0.0015
value (n 44) (n 44)
Snaith’s Irritability Questionnaire – 3 (2–5) 5 (3–9) 411.5 NS
anxiety subscale (n 34) (n 35)
Snaith’s Irritability Questionnaire – 3 (2.75–5) 5 (2–8) 478.0 NS
depression subscale (n 34) (n 35)
inward irritability (n 34) (n 35)
outward irritability (n 34) (n 35)
a
References for psychiatric measures are in text.
b
Bonferroni corrected.
3 negative discrepancy values – indicating that the patient’s memory problem was
evaluated as more severe by the patient than the carer (i.e. poor insight).
To obtain a quantitative assessment of insight in terms of the size by which evalu-

ations were discrepant, the discrepancy values for all 19 items were added up for
Table 8.3 Neurological and psychiatric groups compared on main neuropsychological measurements
Neuropsychology Neurological Psychiatric Mann– Significanceb

measurea group group Whitney U 2-tailed
Verbal IQ 96.5 (85.25–106.75) 103 (90–112) 518.5 NS

(n 44) (n 31)
Arithmetic 9 (7–12) 11 (8–13) 565.5 NS
(n 46) (n 31)
Block Design 9.5 (7–12.25) 12 (9–14) 525.5 NS
(n 50) (n 31)
Digit Span 9 (7–11) 10 (7–11) 688.0 NS
(n 51) (n 32)
Fragmented Letters (VOSP) 19 (18–19) 20 (19–20) 355.5 P 0.0075
(n 47) (n 28)
Similarities 8.5 (6–11) 11 (9–13) 479.0 P 0.03
(n 50) (n 32)
Vocabulary 9 (8–12) 11 (8–13) 612.5 NS
(n 50) (n 32)
NART IQ 106 (96–116) 111.5 (97–117) 735.5 NS
(n 50) (n 32)
McKenna Naming Test 17 (9–21) 24 (19.75–26.25) 260.5 P 0.0015
(raw score) (n 47) (n 30)
Verbal Fluency (using ‘S’) 12 (7–18.5) 16 (10.5–17) 431.5 NS
(n 41) (n 29)
Wechsler Memory Scale: 16.5 (4–38.5) 63 (28–86) 185.5 P 0.003
Passages – immediate recallc (n 32) (n 27)
Wechsler Memory Scale: 8 (2–35) 51 (35.5–78.5) 110.5 P 0.0015
Passages – delayed recallc (n 29) (n 25)
Wechsler Memory Scale: 31.5 (11.25–69.25) 94 (57–99) 85.5 P 0.003
Design – immediate recallc (n 26) (n 19)
Warrington Recognition 3 (3–9) 10 (6–12) 334.5 P 0.0135
Memory Test: Words-50c (n 42) (n 30)
Warrington Recognition 5 (3–8) 8 (7–9) 223.0 P 0.009
Memory Test: Faces-50c (n 32) (n 28)
a
References for the neuropsychological tests are in text.
b
c
Raw scores have been age adjusted to give scale scores (Warrington) and percentiles (Wechsler).
each patient. Values were added up numerically, irrespective of direction (i.e.

whether positive or negative) and the size of this global figure was interpreted as
reflecting the patient’s insight (thus, the greater the figure, the more discrepancies
and therefore lower insight held by the patient).
262 Conceptual
Table 8.4 Comparison of total insight scores (as functions of discrepancy values on the MIQ) between
neurological patients and psychiatric patients
Neurological group Psychiatric group Mann– Significancea

Discrepancies on MIQ (n 56) (n 44) Whitney U 2-tailed
Total discrepancy score 10.50 (7.00–15.00) 11.00 (7.25–16.00) 1143.5 NS

Total positive discrepancies 5.00 (2.25–11.75) 3.00 (1.25–5.00) 773.0 P 0.003
Total negative discrepancies 3.00 (1.00–5.00) 7.00 (3.00–12.50) 662.5 P 0.0003
a
To take account of the direction of the discrepancies, the sum of the positive and
negative discrepancies were separately calculated for each patient. Results are
shown in Table 8.4.
The results show that there is no significant difference in the total discrepancy
scores between the patient groups. However, the neurological patients show sig-
nificantly more positive discrepancies than the psychiatric patients and, conversely,
the psychiatric patients show more negative discrepancies than the neurological
patients. This indicates that the neurological patients evaluated their memory
problems as less severe than their carers whereas, the psychiatric patients evaluated
their memory problems as more severe than their carers.
Grouped insight scores

The 19 discrepancy values were parsed out in terms of the four areas of problems,
i.e. with respect to general functioning, memory, language and cognition. The
patient groups were compared on their insight into each area. The results are
shown in Tables 8.5 and 8.6.
Table 8.5 shows a comparison of the distribution of discrepancies (positive, zero
and negative) in relation to each area between the neurological and the psychiatric
groups.
Table 8.6 shows a comparison of the size of insight held in relation to each area
between the neurological and psychiatric groups.
Compared with the psychiatric group, the neurological group showed signifi-
cantly more positive discrepancies but less negative discrepancies. This is consist-
ent with reported results indicating that neurological patients evaluate their
memory problems as less severe than their carers. The opposite was true for the
psychiatric patients who, compared with their carers, evaluated their problems as
more severe. Interestingly, both groups showed a higher relative frequency of neg-
ative discrepancies in the area of language, indicating that they both tended
Table 8.5 Distribution of insight responses compared between neurological and

psychiatric patients in relation to the four areas on the MIQ: general, memory, language
and cognitive
Neurological group Psychiatric group Chi-squared

Clinical area (n 56) (n 44) (D of F 2)
General function 19/30/7* 10/25/9 8.75 (P 0.05)

Memory 18/29/9 7/21/16 6.73 (P 0.05)
Language 14/26/16 5/17/22 5.73 (NS)
Cognitive 17/29/10 5/23/16 7.28 (P 0.05)
* (a/b/c): a distribution of positive discrepancies.

b
distribution of zero discrepancies (i.e. concordant responses).
c
distribution of negative discrepancies.
Table 8.6 Neurological and psychiatric patients compared on insight scores in relation to
the four areas on the MIQ: general, memory, language and cognitive
Neurological group Psychiatric group Mann– Significance

Clinical area (n 56) (n 44) Whitney U 2-tailed
General function 1.00 (1.00–3.00) 1.00 (1.00–2.00) 1025.5 NS

Memory 3.00 (1.00–6.00) 3.00 (1.00–5.00) 1141.0 NS
Language 1.00 (0.25–2.00) 2.00 (1.00–3.00) 952.0 NS
(Bonferroni
correction:
P 0.16)
Cognitive 2.00 (1.00–2.00) 2.00 (1.00–5.00) 1154.5 NS
to evaluate their language function as more severely impaired than their carers did.
In quantitative terms, both groups showed similar degrees of impaired insight (i.e.
no significant difference in size of discrepancies) in each area.
8.2.3 Discussion of results

The most important finding from this study, from the perspective of this chapter,
is the difference in the type of insight found between the two patient groups. Thus,
whilst both the ‘neurological’ patient group and the ‘psychiatric’ patient group
showed a similar range of total insight scores (Table 8.4) and a similar range of
insight scores in the different clinical areas affected by memory problems (Table 8.6),
264 Conceptual
they showed differences in the type of insight or phenomenon of insight mani-

fested. The ‘neurological’ patients manifested a phenomenon of insight that was
based on significantly more positive discrepancies and hence, indicated that
patients seemed to show less awareness of memory difficulties, i.e. they were
underestimating their memory problems. On the other hand, the ‘psychiatric’
patients manifested a phenomenon of insight that was based on significantly more
negative discrepancies, indicating that these patients showed more apparent aware-
ness of memory difficulties, i.e. they were overestimating their memory problems.
As emphasised earlier, the issue here was not the detailed exploration of insight in
patients with specific diagnoses. Instead, the issue was that, in a heterogeneous
group of patients with a complaint cutting across diagnostic categories, different
aspects (i.e. phenomena) of insight are elicited. In other words, the broad division
of the patients into those with and those without a neurological basis to their
memory problems yielded two types or phenomena of insight in regards to these
two categories. If we examine these phenomena of insight in turn it can be seen
that whilst each phenomenon can be understood within the rough disciplinary
framework of the diagnostic category in which the phenomenon is elicited, it is
more difficult to marry the phenomena within a unified framework.
Examining first the impaired insight in the patients with the neurological mem-
ory dysfunction, it is apparent, on the basis of the positive discrepancies obtained
in this group, that these patients are underestimating their memory problems (in
comparison with their carers’ evaluations). Hence, given the ‘objective’ presence of
such memory deficits (neuropsychology test results), they could be viewed as having
decreased awareness of their difficulties. Thus, the impaired insight manifested in
these patients, appears to be of a type that relates more to the awareness concept.
Patients may not be perceiving (or rather, may not be perceiving the real extent of)
the impairment that is affecting them. In response to questions about any problems
with their memory, compared with others or compared with previous ability or in
relation to general tasks and capacities, patients’ lack of awareness (or only some
awareness) into the basic impairment is then reflected in their judgements that
they are functioning relatively well. In other words, if patients do not perceive or
experience much wrong with their memory then they are unlikely to judge them-
selves as having difficulties with the memory related problems. Therefore, it would
seem possible that the phenomenon elicited in these patients relates to awareness
in its narrow sense as conceptualised in the neurosciences disciplines and as fol-
lowed by the studies exploring insight in patients with organic memory impair-
ment (e.g. Green et al., 1993; Sevush & Leve, 1993; Starkstein et al., 1997b, etc.). As
we saw from such studies of awareness in dementia (Chapter 5), impaired awareness
in these patients tended to be viewed either as inherent to the disease process (i.e.
resulting from the mental disorganisation consequent to the brain degeneration)
or to some form of motivated denial or indeed to a combination of these processes.

Neuropsychological mechanisms postulated to underlie impaired awareness in
this conceptualisation (excluding denial) have made reference to disturbance of
some generalised awareness system or disturbance of a specific module-linked (in
this case memory) awareness function (e.g. McGlynn & Schacter, 1989; Schacter,
1990).
Alternatively of course, the impaired insight manifested in these patients might
be considered not as reduced awareness in the narrow sense but as reduced insight
in the broader sense. In other words, irrespective of the degree to which patients
may or may not experience the changes imposed by their memory deficits, it is at
the level of their subsequent judgements that insight is impaired. However, this
becomes over complicated. Here it makes sense to follow the other studies explor-
ing awareness in such patients (as well as taking into account the contribution of
the ‘object’ of insight assessment) and take a more parsimonious view of the phe-
nomenon elicited and consider this as a problem of impaired awareness at its basic
level (but see later for a caveat).
Let us examine in turn the impaired insight shown by the patients without the
neurological memory dysfunction (i.e. the ‘psychiatric’ group). On the basis of the
negative discrepancies obtained, it is apparent that these patients are overestimat-
ing their memory problems (in comparison with their carers’ evaluations). Hence,
they could be viewed as either having increased awareness, if we adhere to the same
model as above, or decreased insight in the broader sense of the term, i.e. if
impaired insight is viewed here as of the type relating to the concept of insight
(rather than awareness). If we consider this latter option first, namely, conceive the
type of insight shown by this patient group as belonging to the broader concept of
insight, then, how is the elicited phenomenon to be interpreted? In response to
questions about any problems with their memory as compared with others or as
compared with previous ability or with respect to general tasks and capacities,
patients’ impaired insight can be viewed as resulting from poor or altered judge-
ments concerning their experiences. For various reasons (e.g. mood disturbance,
recent experiences, personality factors, etc.), patients may be experiencing changes
(and drawing inferences about these changes) on the basis of more than direct
perception. In other words, the sense patients make of their experiences may be
affected by a range of different judgements which involve various aspects of gen-
eral and personal knowledge.
On the other hand, if we conceive impaired insight in this group of patients as
arising at the level of awareness (i.e. the direct perception of the impairment), then
their overestimation of memory problems would have to be understood in terms of
increased awareness of a deficit that had no ‘objective’ correlates (in terms of carers’
evaluations or results on neuropsychological tests). Applying the neurosciences
266 Conceptual
framework in this context would mean that one would have to consider such
‘hyperawareness’ as arising on the basis of some sort of stimulation of a generalised
awareness system or a specific module-linked awareness function.
Therefore, the issue arising from this study is primarily concerned with the
question of whether using a single concept or model will help to explain the dif-
ferent types of impaired insight seen in the patients or whether it makes more
sense to view the impairment of insight in each patient group as reflecting, to some
extent, different concepts. In fact, it is difficult to conceive of a unified model that
could ‘explain’ in a plausible way both the ‘reduced awareness’ shown in one group
of patients and the so-called ‘increased awareness’ shown in the other. I would con-
tend that the two phenomena obtained in the different patient groups reflect the
distinction, that has been argued for in this chapter, between awareness in the nar-
row sense and insight in the broad sense.
One further question that could be asked is, given that the same assessment
instrument was used in both groups of patients and that the same ‘object’ of
insight was being addressed, why should the two elicited phenomena of insight
reflect two distinct concepts? Here, it is once again important to look properly at
the ‘object’ of insight assessment. Although the ‘object’ of insight assessment in this
study was ostensibly ‘memory complaints’, it is clear in fact that the actual ‘object’
of insight assessment was different in each patient group. In the ‘neurological’
group, the ‘object’ of insight assessment had to be ‘memory dysfunction’ (because
comparisons were made with ‘abnormal’ results on psychometric testing). On the
other hand, in the ‘psychiatric’ group, the ‘object’ of insight assessment was ‘mem-
ory function’ (because here comparisons were made with ‘normal’ results on psy-
chometric testing). Hence, it makes sense that the different ‘objects’ played their
part in determining the specific phenomenon of insight involved.
The study thus highlights that patients whose memory problems arise from
different causes, manifest different types of impaired insight. This issue would
not necessarily emerge if the patient groups were studied independently. In that
situation, one study would show the ‘neurological’ patients as having poor insight
(or awareness) and likewise another study would show ‘psychiatric’ patients as
having poor insight (or awareness). The possibility of different ‘types’ of mani-
fested impaired insight might not follow in the same way. However, our study
design allowed for the emergence of these two distinct phenomena of impaired
insight (underestimation and overestimation of problems) and consequently
these needed explaining. The implications arising from this finding lie in ques-
tioning the assumption of equivalence between different insight phenomena.
Clearly, the types of impaired insight shown by the patient groups are different
and are likely to be underpinned by different mechanisms. It would make little
sense to search for a common neurobiology (e.g. brain localisation of impaired
insight) of poor insight in both cases. In crude terms, the phenomenon of aware-
ness and the phenomenon of insight are likely to be organised differently in the
brain.
At this point, it is important to stress another issue, in part arising from
the results of this study but one that also may have been misconstrued from the
analysis and justification for the distinction between awareness and insight
made earlier in this chapter. Much of the argument presented for making this dis-
tinc-tion was based on highlighting some of the explicit differences in conceptual-
isations of awareness/insight as explored in the neurosciences and those as
explored in more general psychiatry and psychoanalytic psychology. Here, I want
to emphasise that this was not intended to mean that exploration of awareness in
the narrow sense was exclusive to the neurosciences disciplines and that explo-
ration of insight in the broad sense was exclusive to clinical psychiatric disciplines.
The differences in the way in which insight has been approached and explored in
the different disciplines simply help to illustrate in a particularly overt way the dis-
tinction that is argued for between the narrow and wide concepts of insight.
However, it is a conceptual distinction, a differentiation that is made between two
concepts on the basis of some identified specific differences in meaning. At the
same time, whilst they are distinct, it is clear that they have features in common
and that they interact in particular ways. I have touched upon this already and
in the next chapter I shall examine the structural relationship between awareness
and insight in some detail. In practical terms, it is clear that exploration of aware-
ness/insight in patients is a mixed or combined enterprise in the sense that, gener-
ally, clinicians may evaluate aspects of both awareness and insight in patients.
Patients with various neurological/neuropsychological impairments, depending
on the ‘object’ of insight assessment as well as on the degree of awareness held, may
be asked about their views and judgements concerning the changes in a wider
sense than those captured by ‘awareness’. Hence, insight will be assessed as a com-
bination of both awareness and insight. Similarly, in psychiatry, patients may be
asked about signs (e.g. tardive dyskinesia) of which they may be ‘unaware’, i.e.
they simply are not perceiving in a direct sense the ‘object’ that is observable to
others. Hence, the phenomenon of insight elicited in relation to such ‘objects’
will in fact relate more closely to the narrow concept of awareness rather than to
insight. Likewise, in the study described above, whilst both patient groups manifest
impaired insight predominantly of the one type, the results show a mixture of
both positive and negative discrepancies in both groups (see Table 8.5). In other
words, both patient groups at some points overestimate their memory problems
and at other points underestimate their difficulties. Whilst one has to consider here
also the contribution to the ‘insight score’ from the carers in terms of the accuracy
of their judgements of patients’ problems, it is also likely that combinations of
268 Conceptual
awareness and insight (i.e. wider judgements based on awareness) are elicited in
both patient groups.
8.3 Conclusion
Amongst the many different perspectives on insight in different clinical specialities

and within a single clinical area, the distinction between insight, as a narrow con-
cept (‘awareness’) and insight, as a wide concept (‘insight’), has emerged particu-
larly prominently. Awareness refers to the simplest perception or direct appraisal
of a particular state in an individual. This way of conceiving insight has been pri-
marily employed in the exploration of insight in patients within the neurosciences
disciplines and, consequently, the phenomenon of awareness has reflected this nar-
row approach. On the other hand, insight refers to more complex and diverse
judgements made by an individual concerning the perceived state. This way of
conceiving insight has been primarily employed in the exploration of insight
within the disciplines of clinical psychiatry and in psychoanalytic psychology.
Thus, similarly, the phenomenon of insight elicited in these clinical disciplines has
reflected this wider approach.
The distinction between awareness and insight is apparent not only from the
explicit descriptions of these concepts in the neurosciences and psychiatry but it
also makes sense when we take into account the respective ‘objects’ of insight
assessment in these clinical areas. Thus, in the neurosciences, ‘objects’ of insight
assessment (e.g. hemiplegia, amnesia, dysphasia, etc.) tend to be objective in nature
(i.e. directly accessible to an external person by observation or by test perform-
ance) and negative in type (i.e. referring to a loss or impairment of normal func-
tion). These features of the ‘object’ of insight assessment, as has been shown in the
previous chapter, determine a phenomenon that is narrow and circumscribed,
i.e. one which reflects the concept of awareness. In psychiatry, on the other hand,
‘objects’ of insight assessment (e.g. schizophrenia, depressive illness, hallucin-
ations, delusions, etc.) tend to be subjective in nature (i.e. experiences which are
not directly accessible to the external person), positive in type (i.e. referring to the
presence of a new or abnormal experience) and/or referring to a more complex
construct (e.g. ‘mental disorder’). In turn, these features of the ‘object’ of insight
assessment determine a phenomenon that is wider and based on a range of differ-
ent judgements, i.e. one which reflects the concept of insight. The principal reason
for this lies in the crucial role of the ‘objects’ of insight assessment in determining
the clinical phenomena. In this case, these latter ‘objects’ simply demand judge-
ments that are constituted by more than a direct appraisal of the ‘object’. Thus, the
phenomenon of insight elicited in relation to an ‘object’ such as ‘mental illness’ or
‘hallucinations’ depends on individuals, firstly, judging a change in their states
(i.e. perceiving a change in the first place or, in other words, being aware of a change)
but then making sense of this with respect to themselves and their experiences
(hence the wider judgements involved). Since perceiving a change (i.e. awareness
of some change in mental state) is inherent to the articulation of subjective com-
plaints, then awareness, whilst a necessary component of insight in psychiatric dis-
ciplines, is not always a sufficient component of insight in these areas.
The clinical phenomena of awareness and insight share some characteristics but
also have distinguishing features which help to determine in practical terms the
division between awareness and insight. Both are phenomena that can be captured
in quantitative terms, i.e. patients can show different degrees or extents of aware-
ness and of insight. However, they differ in the source or focus of the qualitative
features that are captured in clinical assessments. In the case of awareness, the
focus of qualitative aspects determined by awareness measures is directed at the
‘object’ of awareness. In other words, patients are assessed in terms of awareness in
relation to the qualitative aspects of the ‘object’ (e.g. the severity of an impairment,
frequency with which the deficit interferes with function, etc.). In the case of
insight, the focus of qualitative aspects determined by insight measures is directed
at the phenomenon of insight itself. In other words, patients are assessed in terms
of qualitative aspects of insight (i.e. different types of judgements held concerning,
e.g. the nature of their experiences, whether these represent illness, in what way the
experiences impact on their lives, etc.) in relation to the ‘object’. In the previous
chapter, the phenomenon of insight was proposed to be linked intrinsically with
the ‘object’ of insight assessment, though, analysing the way in which the ‘object’ of
insight assessment shaped the phenomenon of insight necessitated an artificial
separation. The point however was that as far as the structure of the phenomenon
of insight was concerned, the ‘object’ and the phenomenon were bound in a
bi-directional relationship. Therefore, structurally the qualitative aspects of aware-
ness are focused on the ‘object’ whereas the qualitative aspects of insight are
focused on the phenomenon.
Another feature helping to differentiate the phenomenon of awareness from the
phenomenon of insight is directionality. The quantitative assessment of awareness
is generally described in terms of greater and lesser degrees but these degrees are all
subsumed below an implicit ‘normal’ level of awareness. We can say that patients
have reduced awareness of an impairment or they may show increased awareness
following, e.g. rehabilitation, but there is not a situation where patients are
expected to show greater levels of awareness than so-called ‘normal’ levels in rela-
tion to an impairment. In contrast, the phenomenon of insight has the potential for
both a reduction below ‘normal’ and an increase above ‘normal’ levels.
The distinction highlighted between awareness and insight is crucially important
because it provides a means of understanding the way in which different clinical
270 Conceptual
phenomena relating to insight are obtained and, furthermore, helps to identify

some of the specific ways in which such phenomena may be different. This carries
implications for research on insight for it helps to clarify ways of determining
equivalence between insight phenomena and thereby decide the limits of general-
ising between studies. In addition, as far as research on the neurobiology of insight
is concerned, the distinction may help to select appropriate phenomena of insight
for studies in this direction.
9
Towards a structure of insight: the

relationship between awareness
and insight
In Chapter 8 it was argued, on theoretical and empirical grounds, that there is an

essential distinction between awareness as a narrow concept and insight as a wide
concept. In consequence, the corresponding phenomena of awareness and insight
could be differentiated on structural (nature of the constitutive judgements involved)
and clinical (contents of individuals’ utterances) grounds. The question addressed
in this chapter concerns the nature of the relationship between awareness and
insight. In other words, whilst a conceptual distinction can be made, it is equally
evident that, given the interchangeableness of terms, overlap of, and generalisations
between empirical studies, awareness and insight must share much in common.
The question is how can their relationship be best understood? Is it possible to for-
mulate an overall structure for insight that can help to clarify this relationship?
This chapter proposes a basic structure of insight in which the narrow and wider
meanings can be integrated. The structure helps to understand the ways in which
individual insight phenomena will be determined and delineated in relation to dif-
ferent ‘objects’ of insight. The clinical determinants and constituents of these
insight phenomena will then be discussed in the light of the overall structure. Lastly,
the implications carried by the model structure of insight for understanding insight
in clinical terms and for directing future research on insight are explored.
9.1 The structure of insight
Throughout this work emphasis has been placed on the range of meanings of
insight evident in the research and contributing to the variety of approaches taken
to assess insight in patients with different clinical conditions. Within the range
of meanings of insight a crucial distinction has been made between insight in its
narrowest meaning as awareness i.e. the direct simplest perception of a particular
stimulus/state affecting the individual and insight in its wider sense as self-
knowledge, i.e. involving more complex judgements made by individuals concern-
ing a particular state. Furthermore, it has been stressed that these latter judgements
depend on, and relate to, an initial awareness of a particular state (though there are
271
272 Conceptual
exceptions/qualifications but these will be discussed later). In other words, it is

apparent that, in order to have insight of a clinical state in the wider sense, the indi-
vidual has to first have an awareness of that state and subsequently, on the basis of
that awareness, he/she can elaborate further judgements. At this stage, therefore,
the relationship between awareness and insight can be tentatively formulated thus:
awareness provides the core element to insight as a whole. For example, to have
insight into his/her obsessive–compulsive disorder, the individual has to have some
awareness of his/her thoughts and behaviours; in order to have insight into mem-
ory impairment, the individual has to have some awareness of difficulties with
memory; in order to have insight into schizophrenia, the individual has to have
some awareness of his/her abnormal experiences, and so on. Translated into a
basic structure, insight must be constituted at its core by awareness. This can be
represented schematically in a simple form as shown in Figure 9.1.
Figure 9.1 shows a simple representation of the structure of insight. The cir-
cumscribed core represents awareness and the arrows issuing outwards represent
the various judgements that can be made in relation to awareness of a particular
state. It has been argued already that insight is most usefully conceived as a mental
Figure 9.1 The structure of insight. A schematic representation of the structure for insight: central
sphere represents core awareness and arrows represent judgements issuing from
awareness of experience
273 Towards a structure of insight: the relationship between awareness and insight
state and as such there are no clearly defined limits to the numbers and types of
judgements that can be invoked (see Chapter 6). Thus, as was seen in studies explor-
ing insight in patients with psychoses, a wide variety of judgements demanded of
patients concerning their experiences have been viewed as constitutive of insight.
For example, researchers have included patients’ views on the nature of their experi-
ences, their judgements as to whether such experiences are pathological, their ideas
on how the experiences affect their functioning or their relationship with others,
their opinions on medication and other forms of treatment, etc. (refer to Chapter 3).
In addition, apart from the range of types of judgements that can constitute insight,
the level of knowledge required for ‘complete’ insight is far from clear and this
again contributes to the lack of clear boundaries around the structure. What level
of understanding should patients have of their illness or experiences? Do they need
to know the details of the problems? To what degree do individuals need to judge
the effects of their experiences on themselves and on the way they perceive and
interact with their external environment? It can be seen that the sorts of judge-
ments that can be made in relation to a particular clinical state (illness, symptoms,
normal experiences, etc.) are infinite and ultimately for clinical/research purposes
will have to be determined and limited by clinicians or researchers themselves.
In contrast, awareness is conceived as a more circumscribed concept. In clinical
terms, patients are viewed as having or not having awareness or having various
degrees of awareness of a particular state. Assessments of awareness are limited to
capturing its quantitative aspects. Qualitative aspects of awareness are, as described
in Chapter 8, directed at the ‘object’ of awareness and as such are constituted by the
attributes of the particular object. This means that awareness itself in comparison
to insight as a whole has more clearly defined boundaries.
It is important to emphasise at this point that the schematic representation of
the basic structure of insight is intended to portray a potential basic structure. In
other words, it is the concept of insight that is represented, i.e. insight as has been
conceptualised within the clinical disciplines from the narrowest to the widest of
theoretical conceptions. As is shown in Figure 1, the outward limits, in terms of the
possible judgements that can constitute insight as a theoretical concept, cannot be
properly demarcated. As a potential structure of insight, however, it provides a the-
oretical framework against which clinical phenomena of insight can be understood
and positioned and delineated as described below.
If the basic structure of insight can be represented as constituted by core aware-
ness underpinning a multiplex of judgements, where does the phenomenon of insight
fit in? The phenomenon of insight has already been defined as referring to that aspect
of insight that is manifested or elicited clinically. It has also been shown that it would
be impractical to think that the phenomenon could capture everything that might
be entailed by the concept of insight. As such, the phenomenon of insight might be
274 Conceptual
thought of as a ‘section’ of the concept or structure of insight; i.e. incorporating

only some of the chosen elements in terms of the types of judgements included.
This could be represented in the same schematic diagram as simply a fraction of
the structure, e.g. the area covered by the triangle outlined in Figure 9.2.
In other words, according to the choice made by clinicians/researchers, both in
relation to a particular clinical state (or ‘object’ of insight assessment) and in rela-
tion to the types of judgements deemed to capture the concept of insight, the phe-
nomenon of insight will encompass a particular fraction of the structure of
insight. For example, the phenomenon of insight in relation to psychosis elicited
using David’s (1990) measure will incorporate some understanding of experienced
psychotic symptoms as being pathological, judgements whether patients consider
themselves as mentally ill and judgements as to whether medication is likely to be
beneficial. On the other hand, the phenomenon of insight in relation to psychosis
as assessed by the Amador et al. (1991) measure will have a different structure
because the judgements demanded by the latter include ones of different contents
Figure 9.2 The basic phenomenon of insight (first level). A schematic representation of the structure
for insight: central sphere represents core awareness; arrows represent judgements
issuing from awareness of experience; and stippled triangle represents phenomenon of
insight
such as the judgements concerning the social consequences of patients’ experiences.

Similarly the measures to capture insight employed by other researchers elicit phe-
nomena of different structures depending on the types and number of judgements
involved (e.g. Greenfeld et al., 1989; Marková et al., 2003).
It is important to emphasise again that such a phenomenon of insight simply
captures the components of the insight structure chosen by the clinician or researcher.
It does not mean that other aspects are not present or experienced by the patient.
It means that, generally for practical reasons, there has to be a limit on the amount
and type of understanding that is sought. Hence, as explained above, the structure
of insight is to be conceived as a potential structure.
However, the structures of phenomena of insight are more complicated than
simply involving sections of the concept of insight (see Chapter 6). It was argued
that the clinical element, involved in the determination of insight, raises additional
problems because of the issue of interpretation that is intrinsic to the elicitation of
the phenomenon. Clinicians have to make a judgement of the patient’s insight and
this judgement will be based on their perception of what the patient says, how the
patient behaves and/or how the patient manages certain tests. Depending on the
measure chosen by the clinician, that judgement will include the interpretative elem-
ents constituted by the clinician/other factors (e.g. the clinician’s particular per-
spective, knowledge, experience, biases, etc.). In other words, different approaches
to assess the phenomenon of insight will influence the structure of the ensuing
phenomenon by incorporating to varying extents the factors relating to the clin-
ician judgement or the carer/family judgements or the factors relating to the
interaction between patient and clinician in an interview situation, etc. (refer to
Chapter 6). Thus, the structure of the phenomenon of insight might better be
represented as shown in Figure 9.3.
Here, the additional bi-directional arrows facing the original phenomenon of
insight represent the interacting influences of the type of approach used to elicit
the phenomenon. The superimposed triangle represents the ‘new’ phenomenon of
insight that ensues. This becomes a different or modified structure because it com-
prises not only of a selected fraction of the concept of insight as determined by the
patient but includes also constituents determined by the individual judgements of
the external assessor and/or the judgements developing within an interactive situ-
ation. For example, the phenomenon of insight in memory impairment will have
a different structure when this is elicited within a clinician–patient interview situ-
ation than when this is elicited by means of a patient questionnaire, and it is dif-
ferent again when elicited using a discrepancy method.
Having outlined a very basic schematic representation of insight as a structure
comprised of a core awareness around which a multitude of judgements arise and
shown the different elements important in the determination of the structures of
276 Conceptual
Figure 9.3 The phenomenon of insight (second level). A schematic representation of the structure for
insight: central sphere represents core awareness; arrows represent judgements issuing
from awareness of experience; bi-directional arrows represent interactional effects of
clinician, type of ‘insight’ measure chosen, interview situation, other external individual,
etc.; stippled triangle represents phenomenon of insight; and superimposed triangle
represents ‘new’ phenomenon of insight incorporating changes as a result of the
interactional effects
ensuing clinical phenomena, let us return to the relationship between awareness

and insight. Although Figure 9.3 shows that phenomena of insight can vary
depending on the types of judgements demanded of patients and depending on
the type of measure used to elicit the phenomena, it could be questioned whether
such differences are particularly important from a strictly structural point of view.
In other words, the differences in the types of judgements demanded and/or the
extent of knowledge elicited will give rise to different clinical phenomena of insight
because of the consequent differences in content of such judgements. However,
if such judgements, focused on making sense of personal experience, are assumed
to share a similar form, then, it could be argued, that this might impose a common
structure to these judgements irrespective of their specific contents. This would be
much in the way that delusions are generally considered as sharing a basic struc-
ture irrespective of their contents and, likewise, obsessional thoughts, auditory hal-
lucinations, etc. To briefly clarify, the structure of a symptom or mental phenomenon
refers to its theoretical framework whilst the form and content have traditionally
referred to the clinical representation of symptoms/mental phenomena (Marková &
Berrios, 1995c). Thus, ‘content’ can be defined as the actual substance of the symp-
tom whereas ‘form’ relates to the modality or medium in which the content is
expressed, such as feeling, perception, thought, etc. (Jaspers, 1948). This is not the
place to explore this issue in detail (and caveats would be needed in specific clin-
ical areas, such as psychoanalytic psychology, where the structure of mental symp-
toms might be considered as dependent on symptom contents as much as their
form). Certainly there are theoretical arguments against this view in that the judge-
ments considered here are not unitary phenomena but a heterogeneous group
which are constituted primarily from secondary judgements. Such secondary judge-
ments are themselves complexes based on a range of other judgements, on various
types of beliefs, on associated feelings, on past experiences, on general knowledge,
attitudes and so on. Thus, although at a clinical level the judgements can be said to
differ in content, this content in turn is dependent on a multitude of mental phe-
nomena which themselves differ in form and content. In other words, there are
theoretical grounds for suggesting that differences in phenomena of insight (in the
broad sense) may be structurally meaningful. However, this issue, as well as that
concerning the location of possible distinctions between judgements, to some extent
remains to be determined empirically. It is highlighted here simply to illustrate that
the nature of differences between phenomena of insight distinguished on the basis of
judgements may be of a different order to the differences in phenomena which are
distinguished on the basis of ‘awareness’ on the one hand and ‘awareness and judge-
ments’ (insight in broader sense) on the other (see below).
As was argued in Chapter 8, the distinction between the phenomenon of aware-
ness and the phenomenon of insight is based on a more striking structural differ-
ence between ‘awareness’ (as a direct perception of an ‘object’) and ‘insight’ (as
‘awareness’ together with the secondary judgements based on the awareness). It is
important, therefore, to examine, in relation to the outlined insight structure, the
determinants of phenomena of insight whose structures focus either on awareness
or on insight in the wider sense. Understanding the ways in which awareness and
insight are determined in this context may help to clarify their relationship in more
detail. Following the argument developed in Chapter 7 concerning the crucial role
of the ‘object’ of insight assessment in determining the clinical phenomenon of
insight, the structure of the phenomenon of insight will be examined in relation to
278 Conceptual
different types of ‘objects’ of insight assessment. For the purposes here, this will
be limited to three types of ‘objects’ of insight assessment, namely, (i) subjective
mental states, (ii) loss or impairment of function, and (iii) specific diagnostic
constructs (e.g. mental illness).
9.1.1 Insight phenomena determined by ‘subjective mental states’

The term ‘subjective mental state’ refers here to any mental experience, ‘normal’
or pathological, that an individual is able to identify in some way as relating to
him/herself; e.g. feelings of happiness, sadness, anger, perplexity, hearing ‘voices’,
‘seeing’ things not visible to others, worrying thoughts, beliefs of special powers,
beliefs of being persecuted, etc. Whether offered spontaneously or elicited on ques-
tioning such descriptions represent the individual’s interpretation of his/her par-
ticular mental state. Thus, as was pointed out earlier (see Chapter 7), awareness of
the mental experience is a prerequisite for such interpretation. Individuals will say
they are hearing voices on the basis of awareness of some new or change in mental
experience that is then interpreted and judged in that particular way. Similarly,
individuals may describe themselves as feeling happy or angry and, in turn, such a
judgement is based on interpretation of a particular mental state about which they
are aware. Awareness of a mental experience is therefore inherent to the formation
of a subjective mental state.
What does this mean in terms of understanding the structure of the phenom-
enon of insight that is elicited in relation to (and determined by) subjective mental
states? It follows that when the phenomenon of insight is assessed in relation to a
subjective mental state, it is not sufficient to elicit awareness (i.e. insight in its nar-
row sense) of the mental state since that would mean, in effect, to elicit only the
subjective mental state itself. Awareness is inherent to the subjective mental state
and cannot be accessed independently of the mental state. Instead, the phenom-
enon of insight determined by a subjective mental state has to relate to the sense the
individual makes regarding the subjective mental state. Figure 9.4 illustrates this
schematically using the original representation.
Ignoring, for simplicity’s sake, the influence of interpretative factors on the phe-
nomenon of insight, Figure 9.4 indicates the area under the triangle as representing
the structure of the phenomenon of insight when determined by subjective men-
tal states. The area represented by the pale triangle relates to the core awareness
whereas the area within the stippled area relates to various judgements made in
relation to the subjective mental state. Since, however, awareness is necessary and
intrinsic to subjective mental states, it is not possible to separate the two and,
hence, in practical or clinical terms, the phenomenon of insight will be elicited
solely in terms of the wider judgements concerning the individual’s views on the
nature and effects of the mental state. For example, an individual recognising
Figure 9.4 The phenomenon of insight in relation to ‘subjective mental states’. A schematic
representation of the structure for insight; central sphere represents core awareness;
arrows represent judgements issuing from awareness of experience; stippled triangle
represents phenomenon of insight; and pale triangle within the stippled triangle
represents the awareness that is intrinsic to, and hence inseparable from, the
subjective state itself
him/herself as feeling happy may describe this as feeling good and bright. In this
sense, he/she is interpreting an awareness of a particular mental state and giving it
a specific name, i.e. happiness. At this stage, the individual would be described as
reporting a subjective mental state but it is unlikely this would be termed insight.
Similarly, a patient complaining of people plotting against him and being unable to
accept evidence to the contrary would be described as reporting a subjective fear/
worry that was not amenable to reasoning (and the clinician might then describe
this as a delusional belief). However, the reporting of the worry on the part of the
patient would not, in itself, be viewed as insightful even though the patient is
reporting this on the basis of an awareness of some change in his/her mental state.
In other words, in both these cases, the reporting of subjective states whilst, by def-
inition, are indicative of awareness of particular changes in mental state, is not suf-
ficient for determining insight. The phenomenon of insight would demand, in
both these examples, further judgements concerning the nature and effects of the
articulated subjective state. In the case of the individual reporting feeling happy,
elicitation of insight into the happiness might, for example, involve judgements
concerning how the happiness affects him/her in terms of general feelings, in terms
280 Conceptual
of perceptions of the world, in terms of behaviours and interaction with others,

etc. In the case of the patient with persecutory delusions, elicitation of insight
might include judgements concerning the origin and nature of his/her worries,
whether these represent some form of reality or whether they might reflect illness,
whether they affect the patient’s functioning, etc. In both these examples, the clin-
ical phenomenon of insight is determined on the basis of further judgements con-
cerning the subjective mental state. Awareness in the narrow sense of perception of
some stimulus or change, by virtue of its inherence to the subjective mental state,
is simply not accessible to elicitation in the clinical situation. Or, in other words,
the nature of a subjective mental state as the ‘object’ of insight assessment is such
that it incorporates awareness within its structure. Awareness of the mental experi-
ence and the articulated subjective mental state on which this is based cannot be
separated clinically because there is no ‘external’ way of verifying the actual subject-
ive mental experience itself.
To reiterate, the phenomenon of insight elicited in relation to subjective mental
states, whilst structurally comprising of both awareness and insight in its wider
sense, clinically will only be accessible in terms of the wider sense, i.e. in terms of
the secondary judgements made in relation to the subjective mental state (Figure 9.4).
Concerning such judgements and indeed those that come into the interpretation
of awareness of a particular mental state in the first place, this is an area of par-
ticular complexity for various reasons.
Firstly, there is little known about how such judgements develop nor what sort
of factors may determine them. The range of insight that can be found in regards
to both ‘normal’ mental states/behaviours and pathological mental states, suggests
that probably a multitude of factors are likely to be important. Some empirical
research has suggested that the type of background general knowledge held by an
individual is likely to influence the sorts of judgements individuals make (e.g. Lam
et al., 1996; Chung et al., 1997); social and cultural factors have also been con-
sidered important in determining judgements not only concerning the sense the
individual makes of his subjective mental state but also in interpreting the original
mental state experience on which he/she determines its name though there has
been little in the way of empirical work exploring this (Johnson & Orrell, 1995;
Clare, 2004). Other factors, more speculative, may include the individual’s past
experiences of similar mental states (Thompson et al., 2001), individual personal-
ity factors (Weinstein et al., 1994; Lysaker et al., 1999; 2002), level of intelligence,
tendency to introspect, family/peer influences, etc. (see Chapter 3).
Secondly, in regards to mental illness, there is as yet no coherent model developed
in regards to symptom (including subjective mental states) formation. Some pre-
liminary suggestions have been proposed in general terms (e.g. Berrios et al., 1995;
Marková & Berrios, 1995b, c) and various models from specialised perspectives
have been put forward in relation to specific individual symptoms (e.g. Garety &
Hemsley, 1994). However, from the perspective of making sense of psychopath-
ology as a whole, in terms of understanding the ways in which symptoms/signs
may develop, the factors affecting these, the assumptions that need to be taken into
account and the extents and limits to which different types of approaches help
acquire such knowledge, much research remains to be done. It is in this context
that further understanding concerning the sort of factors and likely mechanisms
underlying impairment of insight in relation to pathological mental states might
be developed.
Thirdly, and relating to this, there is little knowledge so far concerning the effects
of mental illness as a whole on the judgements made relating to insight. In other
words, in spite of the numerous empirical studies exploring the relationship between
levels of insight and illness/disease variables (refer to Chapters 3–5), the contribu-
tion of the illness itself on different types of judgements has not been clarified. The
situation is different as regards awareness, or insight in its narrow sense (see below),
where research has, with greater validity, indicated some association between
impaired awareness and neurological and/or neurocognitive dysfunction (e.g.
Prigatano, 1991; Derouesné et al., 1999). However, in terms of insight in its wider
sense, i.e. in terms of the relationship between specific judgements relating to
insight and the mental illness itself, then at present little is known. For example,
does having schizophrenia or bipolar affective disorder or a delusional disorder
affect the way in which individuals think about themselves, does it affect percep-
tions concerning themselves and their functioning, are perhaps only some types of
judgements affected or is there a pervasive influence on reasoning? Thus, the ori-
ginal question as posed by the early alienists and echoed by subsequent researchers,
as to whether and/or to what extent a ‘disordered’ mind can judge its own prob-
lems has not yet been answered.
9.1.2 Insight phenomena determined by ‘loss/impairment of function’

(‘objective’ dysfunction)
The term ‘loss or impairment of function’ refers here to a loss or reduction of a
‘normal’ function or ability such as mobility, memory, speech and resulting in,
e.g. hemiplegia, amnesia, dysphasia, etc. This loss or impairment can occur either
acutely as might happen following a cerebrovascular accident or progressively as in
the case of a neurodegenerative disorder such as Alzheimer’s disease. The most
striking difference between this type of ‘object’ of insight assessment and the sort
of ‘object’ exemplified by a ‘subjective mental state’ is that in contrast to the latter, the
loss or impairment in function is something that is in some specific way externally
evident and verifiable. As was discussed in Chapters 7 and 8, this carries important
consequences for the phenomenon of insight that is determined by such an ‘object’.
282 Conceptual
Precisely because the loss/impairment of function can be verified or determined by

an external individual or test, the phenomenon of insight in its narrow sense, i.e.
awareness, can be accessed directly. In contrast to the situation with subjective men-
tal states, a direct comparison between the patient’s perception and the clinician’s
perception (or test result) of the dysfunction is possible. Therefore, the patient’s
awareness of the dysfunction can be elicited directly. Again, a schematic representation
of the phenomenon in this case is illustrated in Figure 9.5.
The white triangle within the core awareness aspect of the insight structure
represents the phenomenon of awareness in relation to loss or impairment of func-
tion. The phenomenon of insight is focused in this case on awareness of the problem/
dysfunction. In relation to the dysfunction, the patient’s awareness is either present
or reduced or absent. Qualitative aspects of awareness are limited to judgements
made concerning the characteristics of the dysfunction itself rather than the wider
judgements demanded in relation to subjective mental states. For example, elicit-
ing insight into memory problems in a patient with dementia might depend on a
comparison between the patient’s perceptions of his/her memory difficulties and
the clinician’s assessment of problems on the basis of psychometric tests. Or, in a
patient with hemiplegia following a stroke, eliciting insight might depend on a
Figure 9.5 The phenomenon of insight in relation to ‘objective dysfunction’. A schematic

representation of the structure for insight; central sphere represents core awareness;
arrows represent judgements issuing from awareness of experience; and white triangle
within the core awareness represents the phenomenon of insight in relation to the
dysfunction. Clinically represented therefore only by awareness. Further judgements
focused on the features of the dysfunction itself (see text)
comparison between the patient’s perception of his/her ability to move and direct
observation of the patient’s movements. Depending on the degree of awareness
held by the patients in relation to such dysfunction, further judgements can be
demanded, generally relating to observable or measurable features of the dysfunc-
tion itself, such as severity of the problem, the frequency with which it causes dif-
ficulties, etc. Clearly, where patients lack complete awareness of the dysfunction,
further judgements cannot be determined.
The phenomenon of insight determined by ‘objects’ of insight assessment relat-
ing to ‘objective dysfunction’ (i.e. loss/impairment of function), therefore, whilst
comprising both structurally and clinically of awareness and insight in its wider
sense, is focused predominantly on awareness, i.e. on insight in its narrow sense.
This results in a more circumscribed phenomenon whose boundaries are fixed by
the limits imposed by quantitative assessment. Patients will have either awareness
of say, a hemiplegia or dyskinesia, or reduced or absent awareness of the same. The
concept of increased awareness, i.e. beyond ‘normal’ awareness does not apply
because the external verification of the dysfunction is carried out quantitatively
and has a finite limit. And, awareness is judged on the basis of a comparison with
this external verification. Thus, a patient who is unable to move a leg can state that
he/she cannot move a leg thus displaying awareness of this problem. Alternatively,
the patient may say that he/she has some difficulty in moving a leg, indicating
reduced awareness of the problem and finally, the patient could say that he/she
is able to move the leg normally, suggesting absent awareness (anosognosia).
However, the patient would not be described as having increased awareness of the
problem. Qualitative assessment of awareness, from the point of view of eliciting
patients’ understanding of a dysfunction, is not ‘measurable’ simply because there
is no external concomitant. Thus, to reinforce the argument from Chapter 8, quali-
tative descriptions around the phenomenon of awareness in relation to dysfunc-
tions are constrained to characterising the dysfunctions themselves. These features
characterising the phenomenon of awareness together with the relative lack of
judgements elaborated in the wider sense suggest that the structure of this phe-
nomenon in relation to verifiable dysfunction might lend itself more easily to
research seeking to explore the neurobiology of awareness.
9.1.3 Insight phenomena determined by ‘diagnostic constructs’

A ‘diagnostic construct’ such as ‘mental illness’ or ‘schizophrenia’ or ‘dementia’
refers here to a different category of ‘objects’ of insight assessment, namely, one
which incorporates not only the identified signs and symptoms of the particular
psychopathology but, in addition, all the elements (social, cultural, historical,
political, etc.) that might contribute to the ‘meaning’ of the term (see Chapter 7).
This makes this category of ‘objects’ very different from the previous types of
284 Conceptual
‘objects’ of insight assessment. In other words, and again, as was argued earlier,
because of these ‘extra’ elements contained within ‘diagnostic constructs’, then in
contrast to the previous ‘objects’ of insight assessment, there is not the same one-
to-one relationship between the ‘diagnostic construct’ and its determinable mani-
festation. Eliciting insight into persecutory delusions relates to judgements patients
are making about a particular mental state they are experiencing. Similarly, eliciting
insight into memory dysfunction relates to judgements patients make about an
‘overt’ or ‘objectively determined’ problem. Eliciting insight into schizophrenia,
however, may require judgements not only of particular mental experiences and/or
problems the patient may be having but also judgements made in relation to a con-
cept that, through its social, cultural and political elements, may be quite distant to
a personal experience. In fact, different sorts of insight phenomena may be deter-
mined by such a construct.
One sort of phenomenon may be elicited where the focus is on the judgements
made by patients based on the sum of individual abnormal mental experiences
thought to be the symptoms and signs of illness. For example, some approaches to
assessing insight in patients with schizophrenia include questions concerning
whether the ‘abnormal’ experiences they are having are the result of mental illness
(e.g. Amador et al., 1991). This can again be represented schematically as in Figure 9.6.
Figure 9.6 shows three triangles extending from the core awareness and incorp-
orating wider judgements. These represent the same sorts of phenomena of insight
that are obtained in relation to subjective mental states (i.e. comprising of both
awareness of a particular mental state, as inherent to the subjective mental state,
and judgements based on this awareness) (Figure 9.4). In addition, these phenom-
ena reach out to a larger stippled triangle which represents judgements that are
based on other information (i.e. not on awareness itself) in terms of general
knowledge, personal views and biases, individual experiences, etc. relating to the
wider elements of the construct. In other words, the composite phenomenon of
insight in relation to schizophrenia in this case becomes constituted of both per-
sonal and more general judgements. As was the case in relation to the phenomenon
of insight determined by subjective mental states, structurally this composite phe-
nomenon is constituted of both awareness and insight in the wider sense and,
clinically, the phenomenon is composed of a multitude of judgements ranging in
complexity. In contrast, however, to the phenomenon of insight determined by
subjective mental states, this phenomenon also includes judgements which are not
purely based on awareness of a particular mental state but are based, in addition,
on the individual’s general knowledge and opinions about the ‘object’ in question.
It could be argued that these latter judgements are likewise important in the for-
mation of the insight phenomenon in relation to subjective mental states. Indeed,
these sorts of factors were raised earlier as likely to influence the sorts of judgements
Figure 9.6 The phenomenon of insight in relation to ‘diagnostic constructs’. A schematic

representation of the structure for insight: central sphere represents core awareness;
arrows represent judgements issuing from awareness of experience; white triangles
represent phenomena of insight in relation to individual subjective mental states; and
stippled triangle represents phenomenon of insight in relation to diagnostic construct as
a composite of: (1) insight in relation to subjective states, and (2) judgements based on
other knowledge/perspectives, e.g. cultural contexts, general views, past experiences
held by patients concerning the nature and effects of subjective mental states.
However, the difference in this case is that, whilst it is likely the factors will inter-
act, there is in addition the added element that perhaps more of the wider judge-
ments which are elicited will be unrelated to the patient’s actual experience. This
can be illustrated further by examining another sort of phenomenon of insight
that might be determined by a construct such as ‘mental illness’.
For example, other approaches to assessing insight in patients with schizophre-
nia include questions which ask the patients directly whether they think they are
suffering from a mental illness (e.g. David, 1990). This could result in a somewhat
different phenomenon of insight as illustrated in Figure 9.7.
Figure 9.7 shows a phenomenon of insight, represented by the stippled triangle,
that is composed entirely of different sorts of judgements in relation to the con-
struct but there is no relationship to any sort of awareness of a mental state or
experienced problem. In other words, and in qualification to what has been said
earlier, in some situations, the phenomenon of insight in the wider sense may not
be dependent on awareness of a particular state. For example, it is possible that a
286 Conceptual
Figure 9.7 An alternative phenomenon of insight in relation to ‘diagnostic constructs’. A schematic

representation of the structure for insight: central sphere represents core awareness;
arrows represent judgements issuing from awareness of experience; and stippled triangle
represents phenomenon of insight in relation to diagnostic construct not based on current
subjective experiences. Therefore, clinically composed of judgements based on other
types of knowledge only, e.g. general views, cultural contexts, personal biases, past
experiences, etc. (i.e. insight without awareness).
patient with schizophrenia may not ‘feel’ ill in any way or may not perceive that
he/she has particular problems and, yet, the patient may judge on the basis of
information given to him/her by others that he/she is suffering from schizophre-
nia. This could be considered similar to the situation where patients with, for
example, silent or asymptomatic cancer are diagnosed with the condition (and
given information about it including management and prognosis), and acknow-
ledge that they have the disease, understand the effects this may have on their life
and the implications for treatment again without necessarily feeling ill in any way.
The phenomena of insight determined by ‘objects’ of insight assessment relating
to diagnostic constructs can therefore be of different kinds. Some will be similar to
the phenomena of insight elicited in relation to subjective mental states and thus
comprise structurally of awareness and insight in its wider sense though clinically
only in insight in its wider sense. Others will comprise both structurally and clin-
ically only of insight in its wider sense and, because of this, clinically the judgements
formed in relation to the construct will not be based on awareness of a particular
state (i.e. relating to experience of components of the construct) but will be based
on other sources of information.
9.2 Clinical and research implications
Having presented a possible structure underlying insight, various questions natur-

ally arise. Most practical perhaps are the questions of how does the proposed
structure help to understand the clinical phenomenon of insight? And, what impli-
cations does the structure carry for future research on insight in psychiatry? This
section addresses these questions by examining in more detail some specific points
highlighted by the structure. Most importantly, however, the proposed structure
represents, in a relatively straightforward schematic form, the conceptualisation of
insight in the light of the theoretical analyses of insight based on the historical and
clinical approaches to the study of insight reviewed in this book. In other words,
the conceptual analysis undertaken here has detailed in a specific way some of the
complexities inherent to the study of insight and argued for distinctions that can
help to address the complexities. This has entailed the examination of a number of
individual problems at various levels and involved, inevitably, some repetitious
arguments. The structure that has culminated from this work, however, can sum-
marise in a simple manner the complex issues that are relevant for both the clini-
cal understanding of insight and for research purposes.
9.2.1 Awareness and insight: clinical and research implications

One of the main points illustrated by the structure of insight is the relationship
between awareness and insight. The structure of insight highlights two issues in this
regard. First, it shows awareness and insight to be separate though related structures.
Secondly, it shows that the relationship between awareness and insight changes
according to the ‘object’ of insight assessment and, hence, according to clinical con-
text. What does this imply for the general or clinical understanding of insight?
In the first place, it means that awareness and insight should not be considered
as synonymous. This is important from a professional (as opposed to lay) perspec-
tive, particularly given the confusion around the interchangeableness of terms.
Individuals evidently can have awareness without insight and insight without
awareness. Or, patients can have good awareness together with poor insight (as in the
case of patients complaining of hearing voices and attributing these to some alien
intervention) and poor awareness but good insight (as in the case of patients under-
standing they are affected by a condition on the basis of information given to them
by others but without any concomitant subjective experiences). In other words, it
makes clinical sense to distinguish between awareness as the primary appraisal of a
particular perception/experience and insight as constituted by the more complex
288 Conceptual
judgements pertaining to a specific experience. The structure of insight makes it

clear that this distinction can be understood at both the clinical level (i.e. mani-
festing itself in the differences between patients’ utterances) and at the structural
level (i.e. implying different underlying processes or mechanisms).
In the second place, the structure of insight shows how the relationship between
awareness and insight is determined to some extent by different ‘objects’ of insight
assessment. Thus, in clinical terms, the phenomenon of insight elicited in relation
to subjective mental states such as depressed mood, anxiety or auditory hallucin-
ations, will mainly reflect the secondary judgements of insight rather than the pri-
mary appraisal or awareness of the subjective experience itself. Insight determined
by subjective mental states has to relate to the sense patients make of their experi-
ences. On the other hand, the phenomenon of insight elicited in relation to ‘object-
ive’ dysfunction such as dyskinesia, amnesia or psychomotor retardation, will
predominantly reflect the extent of patients’ awareness or primary appraisal of the
problem. The relative importance of awareness and insight in the constitution of
the clinical phenomena elicited thus varies according to the clinical context in
which the phenomenon of insight is elicited. Once again this illustrates that not
only will patients be expressing different types of experiences in relation to the
clinical context (or ‘object’ of insight assessment) but that the processes or mechan-
isms underlying such expressions are likely to be different.
The structure of insight also makes clear that there is little evidence that aware-
ness and insight (together with denial and anosognosia) represent different points
of severity on a continuum as has been suggested by some authors (e.g. Ghaemi,
2003). Indeed this is already apparent from the fact that, as was demonstrated earl-
ier in this book, the concepts of awareness, insight, anosognosia, denial, etc. have
different historical origins and have been approached in different ways in relation
to different clinical populations. However, the structure of insight helps to shows
this more clearly by delineating, first of all, a clear division between awareness and
insight as independent though interrelated structures. Thus, as described above,
the difference between awareness and insight is dependent on different underlying
processes or mechanisms, i.e. a difference in kind rather than a difference in grade.
Secondly, the structure of insight shows that further divisions can be postulated
between insight phenomena depending on the various judgements involved. The
differences between such subsequent insight phenomena therefore would be depend-
ent on the contents of judgements rather than on a different degree of severity or
intensity of one particular judgement.
The structure of insight thus helps to clarify understanding of insight in terms of
the distinctions between awareness and insight and their interrelationship in differ-
ent clinical contexts. In addition, this understanding also carries implications for
research on insight. Most importantly, as far as research into brain representation of
insight is concerned, the distinction between awareness and insight may help to direct
such research in particular areas. For example, the structural differences between
awareness and insight highlighted by the schematic representation of insight suggest
more than that the processes underlying awareness and insight are different. Instead,
the implication is also drawn that whilst awareness can be represented by a relatively
circumscribed and contained structure, by contrast, insight is conceived as a structure
whose boundaries are undefined and whose content encompasses limitless judge-
ments. The arguments supporting this structural distinction were expounded earlier
when the characteristics of the respective phenomena were delineated, for example,
in terms of qualitative and quantitative aspects, directionality, etc. (refer to Chapter 8).
The proposed insight structure however shows this difference in an explicit albeit
simplistic way. From this, though, it follows that research aiming to explore possible
brain representation or neurobiology of insight might more usefully focus on aware-
ness rather than on insight in its wider sense. In other words, it would seem to be a
more legitimate enterprise to be exploring associations between brain function and a
structure that, because of its circumscribed nature, is not only more reliably accessed
but is also likely to be underpinned by a common and consistent mechanism.
Secondly, again from the perspective of research into brain representation, and
following from the above, it makes sense to concentrate on eliciting phenomena
which are constituted primarily by ‘awareness’ as opposed to ‘insight’. To this end,
the dependency of insight phenomena on their ‘object’ of insight assessment indi-
cates that exploring insight in relation to, for example, ‘objective’ dysfunction will
determine a phenomenon that will more meaningfully lend itself to such correl-
ational research. On the other hand, exploring insight in relation to ‘subjective men-
tal states’ or to ‘diagnostic constructs’ will determine phenomena that are constituted
mainly by the wider judgements pertaining to insight and, as such, are unlikely to
associate consistently with a specific neuronal system.
Apart from research into the neurobiology of insight, the structure of insight
carries implications for research on insight in psychiatry in other directions. In
particular, it is evident that much research is needed to develop further under-
standing around the nature of phenomena of insight in the wider sense. Here, as
indicated earlier, many questions need exploring both from a theoretical perspec-
tive but also by empirical means. For example, it seems plausible, though needs
empirical testing, that some insight phenomena, based on particular types of judge-
ments, might be of more predictive value, in terms of prognosis or quality of life,
than other insight phenomena. Similarly, it might be that phenomena of insight
based on different judgements may be clinically important or useful in different ways.
Again this would need addressing empirically. Other questions alluded to earlier
concern the possibility of further distinguishing between different insight phenom-
ena. In other words, might there be some validity in making further distinctions
290 Conceptual
between insight phenomena based on the types and contents of judgements involved?
In a different vein, but crucially, research into insight might usefully concentrate on
exploring the factors that might be important in the formation of the judgements
that constitute insight. For example, one important focus here might concern distin-
guishing between ‘illness’ factors (e.g. current mood, past experience of similar states,
cognitive problems) and non-illness factors (e.g. cultural, social and environmental
influences). In addition, and as mentioned earlier, research may need to address
the question of ‘symptom’ formation, i.e. look at developing models for the ways in
which mental symptoms may arise and be expressed.
9.2.2 Determinants of the phenomenon of insight: clinical and research implications

The other main point illustrated by the structure of insight is the location and
structure of the phenomenon of insight both within the concept of insight as a
whole, and within the external context in which it is elicited. There are several
aspects of this that are highlighted by the schematic representation of insight and
which are important for the clinical understanding of insight and which also carry
implications for future research.
First, the structure of insight shows clearly the distinction between the clinical
phenomenon of insight and the theoretical construct. This helps to understand
that the phenomenon of insight, that is that aspect of insight which is elicited clin-
ically, is not to be considered as equivalent to insight as this is viewed in its theor-
etical totality. The phenomenon of insight can only represent an aspect of insight.
In other words, it would be impractical to attempt to determine insight clinically
in terms of all its possible potential constituents.
Second, the schematic representation of insight shows the phenomenon of insight
to be a product not only of the theoretical construct of insight but also of external
influences. In terms of the latter, two such influences are clearly identified. Thus,
firstly, as already described in the previous section, the ‘object’ of insight determines
significantly the relative contribution of awareness and insight to the structure of the
insight phenomenon elicited. Assessing insight into memory dysfunction or dyski-
nesia, for example, elicits a phenomenon whose structure is focused mainly on
awareness. On the other hand, assessing insight into schizophrenia or into psychotic
experiences elicits a phenomenon whose structure is focused mainly on the judge-
ments that constitute insight in the wider sense. Secondly, in addition, the phenom-
enon of insight is also seen to be influenced by the specific method employed to
assess insight. Figure 9.3 represents this influence simply by the presence of the exter-
nal arrows causing a change in the resultant phenomenon which becomes recon-
stituted through the effects of such influence. Thus, the individual judgements,
experiences and interactive factors of an external assessor will contribute to the final
insight phenomenon elicited. Similarly, tests based on various discrepancies will
contribute to the resultant structure of the elicited insight phenomenon. Once again
the grounds for this have been put forward previously (Chapter 6) but the
schematic representation of insight helps to bring this out in a more explicit way.
In turn, this helps to understand the factors likely to influence the assessment of
insight and expression of insight in a clinical setting.
Third, the schematic representation of insight and the phenomenon of insight
situated against this framework highlight the descriptive nature of this model.
In other words, the structure of insight, both as a concept and phenomenon, is
depicted in terms of its possible and potential constituents and their likely interre-
lationships. On the other hand, mechanisms postulated to underlie changes in
insight, such as denial in its psychodynamic sense or specific neuronal dysfunction
or others, have to be addressed separately. The essential point, however, is that
exploration of such mechanisms are necessarily dependent on an understanding of
the insight phenomenon at its descriptive level.
Knowledge concerning the determinants of insight phenomena also carries
implications for further research. Thus, understanding about the way in which dif-
ferent ‘objects’ of insight assessment can determine a particular phenomenon of
insight allows for a clearer appreciation of the structure of the phenomenon that is
elicited. In turn, from a research perspective, this allows for more valid compari-
sons between phenomena of insight elicited in studies within and between clinical
areas. Furthermore, it also enables researchers to choose and devise measures which,
on theoretical grounds, can most usefully assess the particular phenomenon under
study. Likewise, understanding about the contribution of judgements made by clin-
icians, instruments and the interactive situation towards the formation of the
clinical phenomenon of insight allows for a clearer appreciation of the structure of
the insight phenomenon elicited. Again this is important from a research perspec-
tive as such factors may be important to take into account when exploring insight
in patients and when making comparisons between different insight phenomena.
In addition, this is an area where empirical work would be useful in order to help
determine the levels and types of influence possessed by different insight measures.
Such knowledge, in turn, would be important once again for choosing a particular
method of assessing patients’ insight in different clinical situations.
9.3 Conclusion
Clinical exploration of insight is hampered, amongst other things, by complexities

inherent in the concept of insight itself. Based on identification and individuation
of some specific problems contributing to the complexities, a basic structure for
insight has been proposed and schematically represented. The structure revolves
around the distinction made between awareness and insight and proposes that,
292 Conceptual
in relation to any self-experience, awareness forms the core around which insight,
in terms of more complex and elaborate judgements, is constructed. Although
judgements forming the wider structure of insight are shown as independent
entities issuing from the core awareness, it is understood that this is an oversimpli-
fication and that relevant judgements are elaborated not only on the basis of
awareness but on the basis of and interaction with other judgements. For the pur-
poses here, the crucial issue is the fundamental distinction between awareness
and insight. Whether subsequent distinctions between different levels of judge-
ments are possible is a matter for further theoretical and empirical research.
The structure provides a framework against which clinical phenomena of insight
can be defined and delineated. Different ‘objects’ of insight assessment determine
phenomena of insight that differ structurally and clinically mainly on account of
the relative proportion of awareness and further judgements in their constitution.
The structure provides the space to show the added contribution of external fac-
tors (i.e. in terms of clinician/measure contribution) to the determination of the
insight phenomenon. The focus on the ‘object’ of insight assessment allows the
external factors contributing to the phenomenon of insight to be considered more
specifically in relation to the nature of the ‘object’ itself. In these ways, the structure
of insight helps to organise understanding about clinical phenomena of insight
explored in different clinical situations. In addition, it helps to identify areas where
research may usefully focus.
The relationship between awareness and insight is evidently not straightforward
and it has been argued here that the terms are not synonymous. Individuals are
able to have at the same time poor awareness and good insight and conversely good
awareness together with poor insight. The structural distinction between aware-
ness and insight suggests that research aimed at exploring the nature and correlates
of insight needs to make a like distinction since different approaches to such study
may be required in each case.
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326 References
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Index
‘Aha’ experience 40, 43, 47, 48, 63 compliance with treatment 66, 71, 78,
amnesic syndrome 44, 133, 134, 136, 139, 122–124, 207
144, 146–148, 191, 230, 235, 257 Condillac, E.B. 7, 8, 10, 298
anorexia nervosa 89, 102, 119 Conrad, K. 31, 32, 298
anosognosia 103, 110–142, 144, 148–155, conscience personelle 18, 19
165, 166, 185, 200, 208, 211, 221, 222, conscious awareness system 138, 265
236, 240, 244, 288 consciousness 5, 6, 13, 18–20, 22–25, 30, 32,
Anton, G. 129, 294 34, 35, 50, 131, 136, 145, 146, 149
apperception 7, 32, 34 Cousin, V. 19
Arndt, E. 28, 33, 245, 294 creative insight 41
Aschaffenburg, G. 28, 29, 33, 294
Assessment and Documentation of Dagonet, M.H. 20–23, 33, 299
Psychopathology (AMDP) – insight deductive insight 55
items 73, 79, 80, 85, 93, 94, 98, 104, 112, Delasiauve, L.J.F. 9, 11, 12, 14, 15, 17, 300
117, 120 dementia 27, 44, 65, 128–130, 133, 140,
associationism 10, 34, 37, 38 151–193, 220–225, 235, 239, 257, 264
awareness questionnaire 135, 143 Alzheimer’s disease 162, 166, 167, 189,
191, 192, 258
Babinski, M.J. 129, 294 frontal lobe dementia 166
Baillarger, J.G.F. 14, 22, 295 Huntington’s disease 154, 158, 166, 167,
behaviourism 35 191, 192
Billod, E. 15–17, 32, 33, 296 Parkinson’s disease 158, 166
bipolar affective disorder 80, 83, 86, 95, 97, Pick’s disease 166
99, 100–108, 112, 114, 116, 117, 120, 220, vascular dementia 167, 258
235, 281 denial 65, 69, 120, 124, 125, 129, 130, 134,
blindsight 147, 148 140–144, 152–154, 158, 165, 166, 187,
blindtouch 147, 148 200, 244, 246, 247, 265, 288
body dysmorphic disorder 101, 117, 119 denial of illness questionnaire 88
Brentano, F. 6, 219, 297 depression 92, 94, 95, 100, 108, 114, 116, 117,
Brown Assessment of Beliefs Scale (BABS) 120–122, 143, 157, 161, 162, 165, 183,
90, 100–102, 117, 119 185–189, 193, 220, 257
327
328 Index
Descartes, R. 5, 6, 145, 300 insanity – total 8, 9, 11, 12, 18

descriptive insight 52, 229, 246 insanity – partial 8–12, 14, 18, 32
Despine, P. 18–20, 22, 23, 25, 32, 300 folie lucide 18
Dilthey, W. 6, 7, 300 folie raisonnante 8, 18
double awareness 21, 24, 149 lypemania 9, 14, 21
doubling of personality 21 manie sans délire 8
Duncker, K. 39, 45, 46, 301 monomania 9, 14
dynamic insight 51, 58, 230 moral 10
pseudo-aliénés 17, 18
Ehrenfels, C. von 36, 301 pseudo-monomanie 14
emotional insight 50, 51, 53, 55, 57, 60, 63, insight
230, 246 history 3–33
empathy 55, 56 clinical associations 59–62, 77–126,
Erlebnis 6 142–144, 164–191
Esquirol, E. 8–10, 14, 301, 302 measures 37, 39, 44, 45, 59–62, 67–77,
ethnicity 83, 84 133–136, 157–164
models 40–47, 50–56, 69–74, 136–142,
faculty psychology 10, 11, 32 152–155, 271–292
Falret, J.P. 9, 11, 14, 15, 22, 32, 302 concept/phenomenon distinction 197–218
feeling-of-knowing 43, 45, 47, 148, 149, insight-insightlessness dichotomy 239–240,
163, 231 248
Fournet (no initial) 12, 15, 17, 18, 303 insight in psychosis questionnaire (IPQ) 73,
Freud, S. 6, 48–53, 57, 229, 303 74, 82, 83, 86, 92, 97, 102, 105, 114, 117,
frontal lobe 103, 109–111, 137–140, 143, 185, 124
186, 190, 221 insight scale (IS) 71, 100, 101, 109, 113, 114
functional fixedness 39 insight and treatment attitude questionnaire
(ITAQ) 70, 75, 79–86, 89, 92–95,
Gall, F.J. 10, 11 97–100, 102, 104–107, 109, 110,
Georget, E. 4, 5, 10, 11, 24, 304 112–114, 116, 117, 120, 123, 124
Girard de Gailleux 15, 16, 304 intellectual insight 50, 51, 53, 55
Guislain, J. 9, 14, 198, 305
Jaspers, K. 6, 25, 29–31, 33, 245, 307
head injury 129, 133–135, 139, 142, 159,
220, 258 Koffka, K. 36–38, 42, 308
Hering, E. 145, 306 Köhler, W. 12, 36–38, 40–42, 45, 308
Hobbes, T. 7 Korsakoff, S.S. 144, 308
Husserl, E. 6 Kraepelin, E. 29, 309
hypochondria 19, 21, 28, 29 Krafft-Ebing, R. 13, 309
implicit memory 145–148, 191, 192 Leibniz, G.W. 7, 145

inductive insight 55 Lewis, A. 25, 26, 30, 33, 309
information-processing 42, 45–47, 153, 230 Littré, E. 20, 21
introspection 6, 32, 34, 35, 42, 157, 210 Locke, J. 6–8, 10, 18, 310
329 Index
mania 27, 29, 31, 94, 99, 101, 105, 112, prognosis 66, 78, 87–90, 201, 286, 289
115–117, 119–121, 125, 190 prosopagnosia 147–149
Maudsley, H. 11, 24–26, 32, 313
Maury, A.L.F. 15, 313 reflecting mirror 56
memory insight questionnaire (MIQ) Reid, T. 10, 318
257–259, 262, 263 right hemisphere 47, 137, 154, 186, 190, 221
metacognition 43–45, 65, 145, 148, 149, 152,
153, 163, 209 scale to assess unawareness of mental
Morel, B.A. 15, 16, 22, 32, 314 disorder (SUMD) 71–73, 79–83, 85–87,
90, 92, 93, 95–100, 102, 105–109,
negative-positive dichotomy 238–239, 111–114, 116, 117, 124, 125
248, 268 schedule for assessing insight (SAI) 71,
neutral insight 51, 229 79–86, 92, 94–97, 99–109, 112–114, 116,
117, 124
‘object’ of insight 41, 45, 129, 156–160, 165, schizoaffective disorder 80, 83, 86, 92, 93,
183, 190, 193, 196, 197, 215, 219–242, 95–117, 124, 221, 235
247–257, 265–269, 271, 273, 274, 277, schizophrenia 31, 32, 59, 77, 80, 83, 86,
281, 283, 284, 286–290, 292 91–117, 121–125, 201, 204, 208,
obsessive-compulsive disorder 19, 27, 89, 90, 220–222, 235, 239, 268, 272, 281,
101, 117–119, 220, 272 283–285, 290
ostensive insight 52, 58, 63, 229, 246 seasonal affective disorder 96, 120
self-appraisal of illness questionnaire (SAIQ)
Parant, V. 22, 23, 25, 33, 245, 316 73, 82, 83, 108, 109
parietal region 137, 139 self-consciousness 6, 7, 130, 152, 155,
partial insight 67, 158 232
patient competency rating scale (PCRS) self-consciousness questionnaire 159
135 self-deception 121, 125, 210
patient’s experience of hospitalization (PEH) Spurzheim, J.G. 10, 11, 22
73 subjective-objective dichotomy 237–238,
phrenology 10, 32 241, 248, 268
Pick, A. 13, 27, 28, 30, 33, 245, 316 suicidality 122, 191
Pico della Mirandola, G. 5, 316
Pinel, Ph. 8–10, 13, 316, 317 temporal lobe 110, 139
Plato 5, 317 transference 54, 56, 58
Positive and Negative Syndrome Scale trial-and-error learning 36, 42
(PANSS) – insight item 72, 79, 80, 82, 83,
86, 93, 95–102, 105–114, 117, 123, 124 unconscious processes 48–53, 56, 57, 62–65,
Present State Examination (PSE) – insight 142, 145, 152, 199, 210, 246
items 67, 72, 79–83, 85, 92, 94, 104, 107,
112, 116 Verstehen 6, 32, 34
Prichard, J.C. 8, 10, 24, 317
problem-solving 37–42, 44, 47 Wertheimer, M. 36, 38, 39, 325
productive thinking 38, 42 Wundt, W. 7, 34, 326

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Cambridge University Press

© Cambridge University Press 2005

This publication is in copyright. Subject to statutory exception and to the provision of

First published in print format

isbn-13 978-0-511-13970-3 eBook (EBL)

isbn-13 978-0-521-82518-4 hardback

Part I Historical and Clinical 1

Part II Conceptual 195

Historical and clinical

Exploring the history of insight in mental disorders is complicated by a number of

1.1 Historical contexts

1.1.1 General contexts

was conceived as the entirety of an individual’s experience, comprising internal

1.1.2 Insanity and the conceptualisation of madness

views around the notion of insanity as an all-or-none phenomenon. Instead, the

Another form of partial insanity was introduced by Prichard in England as

1.2 History of the word

1.3 History of the concept

1.3.1 French views

himself request prolongation of admission (p. 32), or a feeling of impending illness

Table 1.1 Prevalence of awareness in patients admitted to Vaucluse asylum between

He then subdivided this latter category into:

experiences. Billod viewed this contradiction between their awareness of ill-

Exploring the concept of awareness further, Billod observed that following

responsibility for criminal acts) as something that could be reduced proportionately

he nevertheless conceived madness as wider than just brain disease. Indeed

allowing for some anachronistic interpretation, this could be viewed as a point

1.3.2 British views

He reiterated this several years later: ‘consciousness is the dependent phenomenon

forming a judgement of this. He considered the notion of awareness in more detail

1.3.3 German views

requirement of objectively correct judgement as one that would be made by an

The psychological perspective: Gestalt,

A significant influence on both the conceptualisation of insight in psychiatry as

2.1 The concept of insight in Gestalt psychology and cognitive psychology

Like Köhler, Wertheimer suggested that the processes underlying productive or

2.1.1 The meaning of insight

(Chapter 7) but at this stage it is important to emphasise this as an important

In subsequent work, Metcalfe (1998) developed the argument further. Responding

2.1.2 Determination of insight

(or ‘objects’) of insight assessment. Thus, for example, the ‘feeling-of-knowing’

2.1.3 Stages and mechanisms underlying insight

1 A mental preparation: where the problem or situation is first confronted and

2 Incubation: where the problem is put aside temporarily. Various mechanisms

It is evident that there is a wide range of descriptions and analyses of possible

2.2 Insight in psychoanalytic psychology

In contrast to general psychiatry, the concept of insight within psychoanalytic

2.2.1 The concept of insight

insight, referring to the knowledge or understanding of one’s unconscious (or only

Interestingly, this conception of restructuring shares strong similarities with the

2.2.2 The role of insight in psychoanalytic therapy

though more distressed subjectively. Interestingly, the use of ‘vignettes’ involving

cognitive-behavioural therapies) on the basis of transcribed statements (and their

underlying assumptions, is more easily delineated (at least in theory). Knowledge

The conceptualisations of insight from the particular perspectives of Gestalt, cog-

The psychological perspectives on insight are important to consider because

Insight in clinical psychiatry: empirical studies

3.1 Definitions of insight and methods of assessment